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25C-051 t s ��HAMpl, Crzfy of Wart4a ptan z t �1111H558Ch118[tts ' DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street • Municipal Building Northampton, MA 01060 r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sup,:-,,;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 backfill), 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 ow er/resident's sign ture requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location {.0 - I ( lip >�f lrz �lJciltt c�1t TMW. T ;it&S S ACil 115 C I IS 1)UARTMEN'T OF EUILDDI G INSPECTIONS 212 Main Street ' Municipal Building 'a j• 'Northampton, Mass. 01060 WOR CER'S COMTENSATION INSURANCE AFFMAVI.T a priucip,- place of busMcss/rts'lc Iac do hereby cc�ify; urlccr tllc pa:cis ,Ind pen;iti n p::rjury, ti?a:. ( I all an employer providing the f0f10'.':iI1C_ '.z;QI'!Cr 5 compcnsfC101] COVC: : C '01 Iny employce.s working on this job: jns =c- Corapam•) clic;NumFxr) ---- (rte�iraon Datc) ( j I am a sole proo;ietor, genPTat C-cutnCrCr G" t?omcowoer (circle one) and Have, hired the, coI]7actors listed beiovv ,.hc, tilt. LO]C t,-•,- � ' Pr'S Oli S: _ orl� cot: pen� �on . (Na= of Contrlctor) (ri-su'nc:. CoIP^";:Tr'-Tolicy NllIIIb--7) + ?'' .t..ICG Datc)- (Name of Contrctor) (Ias mmce Dave) (Name of Contractor) (Ins �s]c0 Cou m,;Polio. Ntllnlxr) =.z; do 1?ate) (Name of Cont:zlctcr) — - (Ins rai�c� Coil]? };'Policy Numl;ir} (Ex I :Ilor Date) (etL�dt-.d�iticeal S':'Ct:I I:C.^tC•a.^:::�:.r...�..�...:.:K:C:a::Ct:i L.-.... - el.•O:G::_:�i:f'� 1 1<LIl it :;olC 1)1 Oj?I1Ct ?i r.illl ;li?'.'C i?O OI: CCU i''' for nn? a home C1'iI]C� 'tiCt.' `1I11I? 11( L: �'�'...... . HOTF:p(casc L%c awn:c t1:zc:.tt•]c FK<;< 1Y S +;r�r, pi ;r. -: n;t> zsancc Cr. m Cr not uxre tit n 4tue0 uni+s in tit ez he 1 ;,i r re: a;` _.,_s z •, ez_r1 hie o=c rx:t cznployc3 u_tir,cr 0) tvcr,z s ar °rn z t (GL!52 :(Sly :ic: y s hncaro« r`cr n c-.c cc Icgal ctatu.of rn=plo)w under thn Wcv Xer't Cc ;o rsl:an?.cL I undo::and that a copy of tha cEitc: ^•r:ay bo fotwnrci J to tln Am,'--z&oirca for tmx covaz&c vrrific:-:10a and that fzaluze to:-_+^trc c'G* -r_;„uzd,—z s4c,icct 25A d i.toL.152 r-in 1u.1 to the im siiio.•�o;c: i::.!pct:ilr.:s cocnistring of a fur-of up to S 1.S -00 n: .'Y i lrt ^i C::of tip to cr,.}- !:.1 civil()CM160 in d�Ic,nn"f.,S!r.,`;Je is(}r:=_:A f rm oC S 1 00.0<3 a dsy i .:in:1 m.. - - roc'cir�%riuta-i e>.1 urc only Signature o T-, f _ iccnrzJl crnr,:mc:. S11CT10N 8: CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone Rein s e're orne mp�o�rement`Contracto ME Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SEGTION 10` WORKERS' COMPENSATION INSURANCE AFFIDAVIT 152,§26,C(6 z _.. 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...... ❑ 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"homeo-,vner" 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 building 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. J Homeowner Signature ni SEGT{ON DESf R P!7�tONVflFt ROPOSEQi1W0RK= chec1ta�I a lica le _. New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[[ ) Other [ ] Brief Description of Proposed Work: tQ Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll 0•Sheet o a, `< o sera d or �. d,i.tionnto existinghotaing�comp °e#e tiefollowin 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. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? In. Type of construction i. Is construction within.100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain 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 SECT�Q� NERAU �ORlZA7ION TO BE COMPLETED WHEN OWNEC{,5gEN1000NTRAC70R gPPL1E5 FOR BUILDING PERMIT I' as Owner of the subject property hereby authorize to act. on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date ✓ I t , as Owner l.Authorized Agent hereby declar that the statement nd information on the foregoing application are true and accurate, to the best of my knowledge a belief. Signed under the pains and penalties f perjury. S (e V-\�`=A Print Name Signature of Owner/Agent Date 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 DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T 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: I y of Northampton Q b'Iding Department 12 Main Street Room 100 rth mpton, MA 01060 e ocGTi�O -58 -1240 Fax 413-587.1272 Qf 81!t10�NGINA pl.... CZt)her <u TION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This secti.otot om tteciti ffice 1.1 Property Address: k �� � a 4 L n c o/k.) EImSL Disfnct GCBD�stnct , SECTION 2-'PROPERTY OWNERSHIP%AUTHORIZED AGENT 2.1 Owner of Record: 4/. /ice Pqyo-- Name(Print Current Mailing Address: IS76141 IQ Signature Telephone 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTlON;3 - ESTIMATED CONST.RUCTIONxCO"STS Item Estimated Cost(Dollars) to be Official Use'Omly com feted by ermit applicant 1. ildi q'n (a) Building Permit Fee 2. Eleciric (b) =:stimated Total Cost of Construction from 5 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number This Section For Official Use Only Building Permit Number: Date I"ssued: Signature: Building Commissioner/Inspectorbf Buildings Date 59 LINCOLN AVID BP-2004-0319 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category. BUILDING PERMIT Permit# BP-2004-0319 Project# IS-2004-0466 Est. Cost: $0.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 12501.72 Owner: BEDNARZ STANLEY W Zoning: URB Applicant: BEDNARZ STANLEY W AT. 59 LINCOLN AVE Applicant Address: Phone: Insurance: 59 LINCOLN AVE NORTHAMPTON MAO 1060 ISSUED ON:9119103 0:00:00 TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE 1/2 OF HOUSE & GARAGE 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 9/19/03 0:00:00 424 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo