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IMAM JARRETT _J._ KRpSOCSKA r'�y �j
ll STRFD — FLOOR 2 — � — —•'-- .e,•.vi l "
70 HAMMON '
WOrtCES7Ek, MA 01014 1723 LOCA'1MON 135 NORTH MAIN STREET
PHONE_ 508-757--8605
FA x: 308 752--8a95 NORTHAMP FON. MA
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DEPARTMENT OF BUIID.ENG Ei�7St'f=0_NS
NSPECTOP 212 Main S treet • Muzikip d B uilding
Nortbxnptnu, MA 01060
HOME O`rVINER EXEIVITTION ACK-NOWLEDGEIMENT
The State of Massachusetts allows the homeowner the right under 780CMR 7108.3.4to act as hislher construction sup, sor. The stare defines "Homeowner" as, "who owns a parcel on which he/she resides or intends to be, a one or two fadwelling, attached or detached structures accessory to such use and/or farm person whho constructs more than one home in a two-year period shall not be e
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 const action supers.:sc, 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 back-ilI).
sonotube holes (before pour). a rough building insaection(before work is
concealed). inrsulation.inspection (if required)and_aTmal_buildina 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 occupancv
until-tbewo rk Amnbe-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
de
a ,,e+-r Kr°S&cc L,, understand the above.
(Rome owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date (o12_ 2107
Address of work
location t� 5 N ./ A i/,i
i
' The Commonwealth of!b_rassachuseizs
-- Department of Industrial Accidents
Office of lnvestz�arions
}� 600 Washing-ton Street
Boston, 14 02111
"' www.massgov/dia
Workers' Compensation Insurance AffidaNjt: Builders/Contractors/Electricians/PIumbers
ADPUcant Information Please Print Ledbly
Name(Business/Org==tion/Individual):
Address:
City/State/Zip: Phone.:
Are you an employer?Check the appropriate box: Type of project(required):
contractor and I
1.[D I am a employe:with 4. � I am a- tract a 6. ❑New construction
employees(full and/or part-time).* have Lured the sub-contractors
T- listed on the attached sheet 7. � Remodeling
12.,� �curl a sore proprietor or partner-
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. employees and have work.' 9. ❑BuiIdin--addition
jNo workers'cow:instn^ance comp.insurance.*`
required.] 5. We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work o racers have exercised their I L Plumbing repairs or additions
myself. [NTo workers'cow. riaut of exemption per MGL 12. Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13.0 Other
employees. [No workers'
Comp.insurance retied-]
Y jP7P-l1=nt mat cae=X3 oox fF nowt a.-so nil out me s=on oeiow snowing therr workers'cornpensanon.poEcy mforn=on.
'Homeowners who submit this affidavit indicating they are doing aU work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must.atrached an additional sheet showing the name of the sub-contactors and state Whether ornot those entities have
employees. If the sab-contractors have emzpiovees,they must provide they workers'comp.pohcy numbs.
I am an employer that is pro vidvzg workers compensation insurance for my employees Below is the policy andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. m: Expiration Date:
Lob Site Address: City/State/Zip:
?attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage.as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1 500-00 and/or one-year imvrisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against life violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cert<fy under the pains and penalties of perjury that the information provided above is true and correct
uafure: Liar-
Phone=:
vfftcuu use only. Igo not write to this area,to be completed by city or town offciaL
City or Town: -- ---_ - - -- - --- —Per-mit/License
Issuing Authoritv(circle one):
1.Board of Health 2.Building Department 3. Citv/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION 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...... ❑
11. Home Owner Exemption
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-vear 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 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 ' Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you -r this permit.
The undersigned"homeowner" ties a d ass responsibility for compliance with the State Building Code,City of
Northampton Ordinances, St e nd Loc Zo s apd-S�ta of Massachusetts General Laws Annotated.
V/Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 0
Or Doors F-1
Accessory Bldg.' Demolition ❑ New Signs [0] Decks [Q Siding[p] Other[[I]
A B o kDescriptio S f.Proposed 5 -�E'r G Dt'I-%vE9
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
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-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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
as Owner/Authorized
Aqent 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.
G,✓��-- - ,ri�,571C Z �—— _—
Print Name /
Signature of Owner/ ent Date
Section 4. ZONING All Information 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-)} ` ..,.,
Frontage
Setbacks Front
Side L:.,. R: ,.. . .. L:t I V_. R: 1
Rear .. .._•�
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved ®-6,
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 Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q 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 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
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 Q NO 0
IF YES, then a Nortnampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit
Building Department Curb Cut/Driveway Permit,
212 Main Street Sewer/Septic-Availabili ty
Room 100 Water/Well Availability
OCT 2 r'�� Northampton, MA 01060 Two Sets of Structural Plam',-
v L tiJ
phone 413-587-1240 Fax 413-587-1272 Plot/site Plans
___-77- Other Speify
c
fir.. , �... n.. ..
"'AQP1C1�1 '" CONS iRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
0000e This section to be completed by office
uo 1.1 Property Address:
'S pori� G S` ' Map Lot Unit
�Lo IZ-E'J P/ AAA
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
gfr�fq- �rnS0(��•. IBS N MAIN Sf �lv2 nJtt� Mr4 afa6
Name(Print) Current fail aih gddp:
Telephone'7 L C! ( a
Signature
2.2 Authoriz d Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed b permit applicant
1' Building 2 (a)Building Permit Fee
�v
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) Z Yj Check Number
This Section For Official Use Only
-Date
Building Permit Number: Issued:
Signature:
- -- --- -- 9----- nspe -- g
Buildin Commissioner/Ins ector ofi Bw m--Id s Date
r
File#BP-2008-0428
APPLICANT/CONTACT PERSON KROSOCZKA JARRETT
ADDRESS/PHONE 135 NORTH MAIN ST FLORENCE (617)230-4198 Q
PROPERTY LOCATION 135 NORTH MAIN ST
MAP 17C PARCEL 237 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out _
Fee Paid Zka27 SP—OS-7
T_ypeof Construction: ERECT 8 X 10 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE ALOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Conunittee
Permit from Elm Street Commission Permit DPW Storm Water Management
Signature 6Pi3ttilding bTficial Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
BP-2008-0428
GIS #: COMMONWEALTH OF MASSACHUSETTS
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-2008-0428
Project# JS-2008-000632
Est. Cost: $2258.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 13285.80 Owner: KROSOCZKA JARRETT
Zoning: URB Applicant: KROSOCZKA JARRETT
AT: 135 NORTH MAIN ST
Applicant Address: Phone: Insurance:
135 NORTH MAIN ST (617) 230-4198 O
FLORENCEMA01062 ISSUED ON.1012612007 0:00:00
TO PERFORM THE FOLLOWING WORK:ERECT 8 X 10 SHED
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 10/26/2007 0:00:00 $25.001254
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo