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DEPARTMENT OF BUILDIINTG INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building s`
Northampton, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as i:is/her construction sups, sor. T he state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be,a one or two anti y
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 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
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v DEPARTMEITT OP DUILDD\,C INSPECT101.'S
212 Tfain Strcct - Nfunicipal Building
Ntorlhampton, Mass. 01060
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W0RIQ R,S C0IYfPENSA770N MSU�CE I�I�t�.v r
_SLR `
(liccusxJpermiticc) _ _. ... .._._.---
%VILL a principal place of businessfresidence at: -- —
�I F II 1_1 5/^ A&P7h4r3 11 h ► �A 0)(/(& (phone:') l��C7
ty/sza.tL,zj P)
do hereby certify, under dhc.paim and penalties of perJury, :hat
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( ) I a m an employer providing the follo%vine %vorkcr's colnocnsz:io, cove Ige for Illy
emplovecs vvorong on tills job:
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(Lam_r-_n= Corer m) - fPelic: Numbccr) (r';przoor, Dom.)
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O I am a sole proprietor, general contractor or homeowner (c c:e one) and have hired
the contractors listed below who llzve, the folio«ing worker's caL-oen_,zdon policies:
(Nmc Oi Conirnaor) (In-uranc c CoInpaSl)7hobc ?�tt1II1=Cr) �_?:JLJ�^n DaIC)
I
(Name of Cooncior) (lns�lrznec Compan�vPotic} Ntsncrr) (l=iWz6on Date)
(Name of Conrraaor) (Insu a.nc: Compamy/Pobcy N:ustu) (Expiration Datc)
(Name of Contractor) (1zSUra. = CompzUy/Poiey Numbs) (Exp mlion Date) .
(ntuda addi-:ocol exct.ifno=o _,v to aaGU(5c iaforruxioo pctaiains to.11
WI am a sole proprietor and have no one worh7_og for me.
( ) I am..a home owner performing all the work myself.
jNOTE:ptr-se be ewwt q..jj3,6emeo.�ven axbo employ Dc zoai to 6o ucx cs=jao c rgau work on.d,.Il-Z of
aot more t1Z a tbsoa tars is wb,i the bomoo-n rd.or ea the Qo tarb zppurtea_r1 tbcen e--c ooc V= ^Uy,oecd_-rcd to tic
ciiployc 3 uiYC the wui c�s
-=p=.= ca Act G Ll1 S 2so 1 5
t C )).applin�w by a bommwve far c lid__or permit ray c+idmoc t1`e
legal—of ea-=Ployx uodor da Work.!.Co.gyp, yioa AaL
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I undestaad tha a Dopy oC thi.mtcmcox oaay be fo—arded to the Dcpen.aamt of IurSatticl Aocdca-e Offioe of 4u+r+Doe for the
oovo-zs=v iGetioa°ad tlau f_UM w situ=lcoverase u3dc 3.c ioa 23A of M()L 111 can lad to the iazposiiioa of eimi=d pca1 l io
00m.irit of a fiat of tap to S 1}00.00 andlor 6=p uoome=of up to ooc y=r eod aiil pmahio in 6c roan or&stop wort;Ord-- aad.
fl=0(5 100.00 s day rpiaa tar
- F«6cpartrr'11 u, Drily
permit Numbcl
K nahrrc t�(-iacrscc/Pcm6L[cc -ate -- d
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SECTION 8:-CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder a .r"�.D ( �7Ga )
License Number
Address Expiration Date
gnature Telephone
eaise ame.mprctvemeei ontra .�� _ M Not Applicable ❑
8 Ci�1.✓1 loo 6/�
Company Name Registration Num er — -
Address Expiration Date
Telephone RV-G)c
SECTION 1'0-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...... ❑
� �� 111
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 posse-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.Aperson 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
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check-all applicable)
New House F--] Addition Replacement Windows Alteration(s) Q Roofing
Or Doors W
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding Other[o]
Brief Description of Proposed .
Work: s,ll'iN T !{•i/�Avers : / Aoe-A rb S�_ U� L2C�c�i/��
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa# h(ew house-an '"r" dd o to extst�nc=aousing� c m�n1e + tMe to�iow"nr g
If -
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. Masscheck 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
SECTION 7a_-°OWNER AUTHORIZATION--T0;BE COMPLETED WHEN
OWN E RS AGENT:OR CONTRACTORAPPLIES`FOR BUILDING•"PERMIT
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'I A Sa/t-j L as Owner of the subject
property
hereby authorize 1 C/t'
to act on my behalf,in all matters relative to work authorized by this building permit application.
�- c. -✓ %
ignature of Ovfner Date -G
as Owner/Authorized
Agen ereby decla that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and l5elief.
Signed under the pains and penalties of perjury.
JAI S-
7/-St-Print Name
S" ature of 94er/Agent Date
Section 4. ZONING All Informatihh Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size i
Frontage
Setbacks Front i ?
Side L , R: ' L:' R:
Rear
Building Height '—
Bldg. Square Footage J % r
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 0 DONT KNOW 0 YES 0
IF YES, date issued:"
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page; �j and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 Date Issued:
C. Do any signs exist on the property? YES 0 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
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IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES r NO
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IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
_ City of Northampton
Building Department
212 Main Street s
Room 100
^"ro Northa pton; MA 01060
`.0" phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTlkl i6T,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1'-SITE IINF6RMATION
Th "dfibm,ta be completed by office
1.1 Property Address:
(.t 3 r4 0 S/
Ci1�7 4,N Jl ' ?nne �, Ouerl'ay Distr cf
k
"�EIm�,Distnct '.� � 4' CB Distract � ,
SECTION'2-'PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
aoe TA 5�7N i Ll3r,?I1? S%
Name(Print) Current Mailing Address:
pe, i gU-(30
Ur !--- Telephone
ignature
2.2 Authorized Agent:
x-13
119me(Print) Current Mailing Address:
4Z 9--c,,)o 7
t5-idnature Telephone
SECTION 3.--ESTIMATED CONSTRUCTIONICOSTS
Item ~ Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building r (a)Building'Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6
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
Date
Building Permit Number�' Issued:
Signature:
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Building rCommissioner/Inspector of Buildings Date
43 FAIR ST BP-2005-0880
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A-248 CITY OF NORTHAMPTON
Lot:-001
Permit: BUiidinQ
Category: BUILDING PERMIT
Permit# BP-2005-0880
Project# JS-2005-1214
Est.Cost: $5500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Joseph Jasinski 100616
Lot Size(sq. ft.): 21605.76 Owner: Joseph Jasinski
Zoning: SR Applicant: Joseph Jasinski
AT. 43 FAIR ST
Applicant Address: Phone: Insurance:
43 FAIR ST (413) 584-0307
NORTHAMPTON MAO 1060 ISSUED ON:3122105 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL SIDING, 2 WINDOWS, DOOR & 3 SQ OF
SHINGLES OVER 1 LAYER
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• Date Paid: Amount:
Building 3/22/05 0:00:00 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo