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11C-026 OQ„'CttAMP�O Gl ity of Word anyton Z � � �iassachnsrtfs m DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street • Municilva 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 sups ,, 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 your), 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 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 au73-_ A f work .�S�4�w2 X Q •�� locatiocatio n y - �, �` C11,i f tT 1•,i t �tt�-i l}�t»t}�f ct t t x �. v �S�iSl AC11176CII7 w Ey1Y m DEPIURTMENT Of' LUILDDI G INSPECTIONS 212 Main Street ' Municipal Builciing NorthaIIlpton, Mass. 01060 WORICER'S COMTENSATION INSURANCE AFMAVIT \vlth a principal place of busiressJres'dence a t- C �j _�i� � C.t</'t.���. --�1'L�(�_-�/w'_v 1 tL►'K�-��_Q 4d�'(gyp 11 i)rt C�=;-----�r� ~`.'�'"'c7 d�� (StTCct/clt,t do hereby Ccr-LI . 1111:+er the p�:ns ,-.na pen2ltic, �i perjury, that O I an an empioyei- providing the compcns�111011 COVC1"f:'vC For my employees working on t?iis job: (1.nS.L=Czz Company) clic;Number) Date) j I a.ci a sole proariotor, general c-n=ac-,-ar c:r homefl���]er ;c�i;cle occ and 1,.ave 'Hired the contractors listed beiov. ;,to the `ollc+ rg `Jofkers compens- DoT, poiie.;s: (N=c of ConLnctor) (II15L�r1C� C^v IT^:::it��011Lf NutIlbc-r) (Name of Connnt ,Or) -- (Z:LSIrarce Co7, pa7,v(Pd1C-y Nl mbcr) (I zpir Lion.Date) (Name of Contractor) i (Insa oI]ce Ct�m;an.,ii'elsc: r�t�s��rt r) - \.ir Co Dat',-) - (Name of Contactor) _ (IasZ:rincz- CotL,7:-Iy/Polite Nu.mb.�i) (MIIC-il "�I::CC:1]S:i;Q:::::•7-Sl(•:::: ^•C:f'/'r•.•:-K:C:L:CY: ltv' 110 IilE. j Gill 1 h0I1?e C�'lllC� i�Ci CSI?1111" A NO•rF::plc;.sc be,:rare tt:st•.��i]c t,c<-,c:���ir-:��-.:o c., 1:,-y IT-:._� t —� ��c:�;,�_u:aanc�a:::'-rt;�=.'m ct:ci;air«•,;,c+x:�«cl!i.� not trice th_u throo unks in c�*.ployca u.�cs llr cacti;ft ar r--:_irn s ((ri,'.S2�s i(si?,at:Ii_a:ic:;!,v a hanro«n:cr for a L"--c cc prTau:r. time Icgal statue of an=ployx unur tLn Wcv c!a Coz-;cr ition!.cL I undo--:tared thL a copy of thii ttat=—=!evy bo fotv.',ua 1 to t!n[Y.tw�tzrr:.:of Is>dzss:riel Acti-ir..�:�Ciuoo of oovaagc vmllrtica and th t f iltut to rc covcr�:un,3. c�,iM 25A aT?.{GI.152 can It--.4i to the m sifian c;cr ji l pccsl:a cocaistmg of a ftnc of up to S 1,OW.00 and'cv ir.:p r:r.zx::i of::p to cn_j;ar r.r.1 civil czuttiu in d'C kxrn C.f.,Sty+'.'ni: f"M of 5100.00 a dsy 1,-161r.1 m.. �cX %uutYZts1 u�c.111y Pcrrnit Nttulb•�-r .__ Si I]1 urt Ot t•tC�:S':C':�1tCr11]iitrr, -�. l Si=C36 N 8W CONS "RUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Ro e r �J License Number Q ®"a CS o 3 3055" Address Expiration Date -Yyw 1z _ y Sign Z Telephone oo� #I/?- Ree s e e m ma o e 'E ont actor Not Applicable ❑ Company Name 17 Registration Number 114A(S-5 1161(6 Address c Expiration Date C� p �LIJVt(iCV Telephone ' of SE T OIlOVItO ERS COMPENSATION INSURANCE AFFIDAVIT(M G L.xc'. 152,§ 25C(6)) ,x 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 istructures.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 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 � 4 SECT = SGRTdO: ©FPROPOSED11Vd.RK checka;ll a lacable New House ❑ Addition ❑ Replacement Windows Iteration(s) Roofing L Or Doors Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ) Siding[ ] Other[ ) Brief De op of PrOAOsed�Work: DA aQQr14a&lh UUw. Mg&t. A7 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. 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 O� EE O NER UHORIZATION 70 BE COMPLEtED WNE�I � COITRACTbR�PPLIES FOR BUfiL DING.PER�IIIT — as Owner of the subject property hereby authorize e'c`�A tZ� C-c�tn a�„ a� to act. on my behalf, in all matters relative to rk authorized by this building permit application. y Signature of Owner Date q 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 ^ ti and penalties of perjury. 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 904160 r Frontage OO p,o Setbacks Front t t . Side L: R:_3 L: R: Rear Building Height Bldg. Square Footage I�UU Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: VA volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Y DON'T KNOW X YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW K 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 1� IF YES, describe size, type and location: D. Ar there any proposed changes to or additions of signs intended for the property ?YES _ NoI IF-YES, describe size, type and location: of Northampton i ding Department 12 Main Street �liL 1 nr ;z 1) Room 100 orth mpton, MA 01060 •58 -1240 Fax 413-587-1272 'p,OF 81!iDING INWEMION APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE 1NFORMATION _. 1.1 Property Address: *` 010-5- r � 3 S:EC TION"2 -'PRO:P1E OWNERSHIP/AUTHORIZED AGE NT 2.1 Owner of Record: Name(Print) M y��o COT Current Mailing Address: G �S��v� e Y F C OTT A Telephone �(�— V3 �6 Signature 2.2 Authorized Agent: _6 1 `S e, Af M r'e )I Name(Print) - Current Mailing Address: Signature Telephone 1 '� 3 SECTION'g3"-.ESTIMATED C'ONSTRUCTI'ON COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee Oppr 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 + 10 Q Check dumber This Section For Official Use:Only Building"Permit Number: :- Date':Issued: Signature: Building CommissionerAnspector of Buildings Date File#BP-2004-0120 APPLICANT/CONTACT PERSON MIENTKA GISELE M ADDRESS/PHONE 4 STOWELL ST (413)584-4386 Q PROPERTY LOCATION 4 STOWELL ST MAP 11 C PARCEL 026 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out _ Fee Paid Typeof Construction: NEW FRONT DOOR DORMER ROOF OVER FRONT DOOR&2 ENTRY DOORS 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9RMATION 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 Committee Permit from Elm Street Commission 22�� 6-16--03 Signature of Building Offi l 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-2004-0120 GIs#: COMMONWEALTH OF MASSACHUSETTS A %-.1w, CITY OF NORTHAMPTON Lot: -001 Permit: Quildft Category: BUILDING PERMIT Permit# BP-2004-0120 Project# IS-2004-0188 Est. Cost: $7000.00 Fee: $75.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor., License: Use Group:— Homeowner as Contractor Lot Size(sg.ft.): 8494.20 Owner: MIENTKA GISELE M zoning.URA Applicant: MIENTKA GISELE M AT. 4 STOWELL ST Applicant Address: Phone: Insurance: 4 STOWELL ST (413) 584-4386 0 LEEDSMA01053 ISSUED ON.817103 0:00:00 TO PERFORM THE FOLLOWING WORK.-NEW FRONT DOOR, DORMER ROOF OVER FRONT DOOR & 2 ENTRY DOORS 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 OccuQangy Signature: FeeType• Receipt No: Date Paid: Check No: Amount: Building 8/7/03 0:00:00 357 $75.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo