25C-051 (2) O O
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DEPARTMENT OF BUILDING INSPECTIONS �
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060 '
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction supc-,•isor. 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, z /3 L 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
1 _
of Nart1jaillpfoll
DEPARTMEA'T Of' BUILDr)�G INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WOP,TC�,R'S COMPENSATION INSURANCE /IFFMA IT
(liccns°v%rcrmiltce) -
v"Ida a principal place of busiress/re:sidenc
(phone -
(StTcc Uci t•i;:ri=:!;�i17
do 11CI"eby CCrl1I)t, d1c. 1)<:1TIS 3iiti pcilai(Ics Oi 7C;I]llrlj' '.IlF+::
O I am an employer providing the Jollov.,:,lc •:orr_cr`s comncnsation coveravc for my
emploVices wor Brig on this job:
(Ins =cz Cor_ipam,) ei-;cr N Lm,lxr) ---- (ET &—a on Date)
j I ani. a sole pronlietor, g'gnPrai c:mirc-or hon,eON';Der (cLcle one) and t-:ave aired
the conuactors listed beiow, 'tot: the `o to :L:g `�orl�ers coLnpen orl ;olicies:
(I Inure of Contractor) (Ins -ncc Comoas,,,:Pclic,' NusntYr} -c-, on Date)
(Name ofcounacl ,or) (izsuanc�z Ccmnan-dPctic,` Numb--r) Date)
(Name of Cone-actor) (Ins'utmacc (_:� t"l }'/i�0�.�, NIIJIII} I� \ ;::QO halej
-`(Name of Contractor) _ (In urancv Comr--n ny!Policy Numb=r)
l 1 Lull a Splc propel( L,of i'.11:1 ha't'e no OI1`� '.'.or .ii 101 ihc.
f. 1 ?ill (? horde Cv-nc" liC!?C il11Ii all
ir
not UK<r th_n ifuoe units in t<i:icdt.1 Iu,».::u.—r=:,c=or a; rr t ccrs111y ccr.:::i:r:
c;ployc-3 un�,cs tFr:vctL,�a cc z•—:_tirn s (<3i"15 t(Sj;.' :ic;by a homco N-r`or r Lc—i c<p-ra:i::: .... roc
' ..is r.
lcgzl ctatur of an cmployx unt:rr tLc W o kcc'a oi,or .ticm!.cL
I undo--ctn d thi_a copy of t}ix ctstcis•mvy to f( ti---,Ied to tln D-j�tn—a of lrgLLtrinl (:i ioo of :A for tlx
oovaagc vaiFic:aioc and that f--du c to ut-.&,-. 25A of MC-L.152 can k_d to tlx im sitiaa of c r i l pc ali:
comisting of a fur-of up to S l SCU.CXJ a;"lrr i :t rc. nx:1 of::p to cr.:}- r-.i civil,>cn ltiu in 34"ofm of
Lem of S 100.00 a day
Fa-�:uutrrtal u>•c«tty j
Ycrrnit Nurzib r — - -- ----'
i '
Jtraaturc t f;
�
.iccn,:cJl
SECTION 8-- CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Ref s e-e a m mp ov`em'ent ont actor Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTIOU40 ..WORKERS' COIYIFENSA,TION INSURANCE AFFIDAVIT(M.G:L.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...... ❑
m
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 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 fu>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 Signatures
R ry
Jr
SEC7IO.I�I� D S R P�TOlVOPROPOSEDWORK the loll 0611ti lle
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing .
Or Doors ❑
Accessory Bldg_ ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ) Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 • Sheet 0
a fflle mouse nd o addil,MMto,e)ff§b 5� 0W!§in : -o fe the fol_low�—n
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?
h. 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
5EC}T10M 1NNE t UT ORfZAT10,N TO BE COMPLETED 1NHEN
0111(V�RS EN OtCOITRACTORAPPLIES FOR BUILDING;PERMIr.
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
1, , 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 J
gnature of Ow W gent if 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:
f
City of Northampton at
Building Department
212 Main Street
Room 100
Northampton, MA 01060 - e
phone 413.587-1240 Fax 413.587-1272 P
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - S'ITE INFORMATION
1.1 Property Address: �� �
This section#plif ''om Fete by offtc�n
,c�Q �✓IJ"� Ntap
Zoned � Overpay tstric
'77 771
3
EImSt�District �� ��-��CB Dts[rtctx�
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name�(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Ag t:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION-3 - ES.TIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official'Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Ele-.rical (b) =:stimated Totat Cost.of
Construction.fr rn 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection ^1
6. Total =(1 + 2 + 3 + 4 + 57) Check Number �S
This Section For Official UseOnl
Building Permit Numbe..r: - Date Issued;
Signature: _
Building Commissioner/Inspector of Buildings Date
r
BP-2004-0319
GIS#: COMMONWEALTH OF MASSACHUSETTS
` 1 t 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(sa.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 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