25C-014 f
pQ'�t1Al`1P�O
Grify of Wox#4ampton V4 z
� � �assachusetfs
DEPARTMENT OF BUILDING INSPECTIONS
IONS /=
INSPECTOR 212 Main Street • Municipal Building
North,unpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction super,,*!sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two family
dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a
home owner."
The building department for the City of Northampton wants any person(s) who seek to
use the home owner exemption, to act as their own construction supervisor, to be aware
that by doing so you become responsible for compliance with state building codes
and regulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before bac!i l),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work(electrical, plumbing& gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
��ttANJ'�O �� -
6 JSICSIAC}ltif+Ct15 -
^z m DEP/'uZT1fENf OF BUILDING INSPECTIONS
212 Main Street Municipal building
Northampton, Mass. 01060 '
woruCzaS COMTENSATION INSURANCE kFFMAVIT
_____----
(l1
vAth a principal place of bush ess/residenc
_
do hereby certify; unt+er the p ins and pen,hies 02 perjure, t}la
I ?rtl an employer providing the foil ov"iI1f; '.ol-k f S GOII9pC;1S�lhOD ror II1}
employees Working on this job:
(Las-l=aS CAIi1pam) ( C1:C;�Viil'11�7Cr1 �Y�:pll�il^��3IC)
j I a-m a sole prow is*-or, general C�onfLT-ac`or or hon-,Co,Woe: (c, cle one) and Have hirt-d
the contractors hsteti belOW ;}no i':S ill tOil..;t^a ;10iitP�S GOi peIl� iOft ;'^!iU:�S:
R,IIISIIC Of COIICI<1CiG<`) (-1A_•L_....1C:; ILOIII_.:::1;rr.G.ICf T1uI71�r) Datc)
(Name of Conn,c,or) _ (Insurance Nulnir_r) (E:p .aiiG Date)
(1�Iame of Contractor) ( na.:`P.IlC t-Q ?n:i/PO!,C. Tvi1II]�%I� '.� ,- C L,at,-
(Name of Cont ac,or) — jas-o mc- Co111r }-6 oticr Numb��r) (i:::r;:-::ic: Date)
(..^.ttadt:ddtUcr it scrd:�::__.... cn:.r::!.�c 'Y C:i:cK•.7-=-_-... ail
><I a-111<un <. SO1C 1?1O1?t1CL'Ji 2i1 have Il0 7II Ol� ii'' tol -IIE
( ) I am a 'home OWnC': i1Ci?C"[Illf� ?ll
?4'0'I.1::plcsc be nwa:c ;)-7.-.-7-:U�
not trKce thu cline unite in a oc; ccrrr111V cc•::
c_ztployc:-3 un:ar the wc:L:z:ar :1.itn i r (G.!S2� !(51';.at:t:=a:icn y a homcorc-=`ar a Ecru it L-
IcSal ctzhu of an employer unur tlzn Wo kcr'c o w z anon Act
I undo_-ztaad thL a copy o:t}ui staters_•auy bo fo:w:vcleJ to ttr M i?, !y OiLc+ Of':: —�:a for tlx
coverage vct�,tc:lioa and ItLt C_.ilttrc to tl+:,!:c cro��t`M ur.�,c:ccGiot?2 S A of?.iGL.152 Gtn lc:d to t}x imj:ositio:s,�f c:=-�1 Ptt='ll=�
coaaistutg of a ftrx of up to S 1,500.00 n:t 'v i^:;ui 2 of::p to cr.:}:..r r.:.I Civil pC=16cs in dr Icnn cf a S!c;
fir=oC S 1 00.00 a diy I.-gil .1 rn..
For d�;utatsz Yil u.c cril y
/J„-� •--7 � � � (_ f Pcrrnit Nuultr.:r ---_--------------�
na tlrt: of i.icon c Ji'crm is
SECTION 8' CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : iN 1L/— -/4'�'°� F� 1
License Number
/-L" 0<J -3 q'3---4
Address Expiration Date
W i f!C; s� j o t 0 c?to
Signature Telephone
I�RegCstet�bmemQent Co//rio,t ac#o 0 Not Applicable ❑
r S
Company Name r Registration Number
Address Expiration Date
A 10 rC G Telephone
SECTION i0 WORKERS!,COMPENSATION INSURANCE.;AFFIDAVIT(M GL.-,c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
1,l�Tf- Q
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be, a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the buildine permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SEGTI.ONT5 a RT,ONf0PR0POSEDYVORK> checlll a I�cable
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ) Siding[ ) Other
Brief Description of Proposed Work: _ 5--/le P a0 F 7 Sf� �"�- 1;s► 45 � �(�;��/�-�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative O Renovating unfinished basement Yes No
Plans Attached Roll O. Sheet 0
sa l°fNe f>o "e""' nd or ddition to:ezisti""ng housing,oompl°e a ff�ie' f0l 1M ng_
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. bimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction
i. Is construction within.100 ft. of wetlands? Yes No. Is construction within 100 yr. floedplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
`SECTON 1 1NNERAUTHORIZATION TO BE COMPLETED VYHEN
211 OWNERS�q ENT CONTRACT. -.PLIES FOR BUILDING PERMIT
r,rv .., M � , :.. .
as Owner of the subject property
hereby authorize to ac:. on
my be in all matt rs relative to work au h ized by this buil g permit application.
Signa ure of Owner Date
as Owner/.Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
p a
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume'&Location)
A. Has a Special Permit/variance/Finding ever been issued for/on the site?
NO DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property?YES_
No
IF YES, describe size, type and location:
1 �
City of Northampton y
Budding Department
212 Main Street
,X]4 -Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address: " Tban tole P I
P t o€fice
AN
4 3'RR"' a s sy'„y^s✓. ,, n '` a ,.y,
^,"*.
A/?3 P—T—LW-jo TO 1 Zone k Ovetla r Dystrict
�w�St.�lStr�iC.t�, .., .� r...'�.,.•� CiQ li)istr,'ct� �"..�_
SECTION 2-PROPERTY'OWNERSHIPJAUTHORIZED,AGENT
2.1 Owner of Record: _ CIO (,j/t3C v `�✓
C-A (:�-'0 1, C �-�}-G jc s G °� .Al-0 e
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Na die(Print) Current Mailing Address:
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building {a)`Building Permit Fee
2. Electrical (b),Estimated_Totaf Cost of
Construction from 6`
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total= (1 + 2+ 3 +4 + 5) ttieckNumber
This Section'For Official Use Onl
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
90 WOODMONT RD BP-2004-1067
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-014 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2004-1067
Proiect# JS-2004-1592
Est.Cost: $1750.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: NORMAN ZALESKY 128482
Lot Size(sq.ft.): 28793.16 Owner: JACKSON CAROLE ANN&DEBORAH M
Zoning.URB Applicant: NORMAN ZALESKY
AT: 90 WOODMONT RD
Applicant Address: Phone: Insurance:
P 0 BOX 53 (413) 268-3553
WILLIAMSBURGMA01096-0535 ISSUED ON:4130104 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 4/30/04 0:00:00 1033 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo