17A-236 (3) 35,
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69
FEC Reg. 100 133
Phone& Fax
I JOHN H. ZIEMINSKI (413)247-9014
BUILDER& GENERAL CONTRACTOR
8 Woodridge Circle
HATFIELD, MA 01038
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" DEPARTMENT OF BUILDI]�G 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 his/her construction sups. i sor. T Ile 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 infection (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
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibly
Name(Business/Organization/Individual): ,/c%/ham / / //.✓S(!j /jGt It_bc-x7;` 6,�q o
Address: t� I)e,o ) C',,c C e
City/State/Zip: Phone#: 3 i -9
Are you an employer? Check the appropriate bog: Type of project(required):
1.0 I am a employer with 4. [� I am a general contractor and I
_�* have hired the sub-contractors 6. ❑New construction
employees(full and/or part-time).
2.[ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have g. Demolition
working or me in an capacity. employees and have workers'
g y p �'• $ 9. ❑Building addition
[No workers' comp.insurance comp. insurance.
required.] 5. [] We are a corporation and its 10.E]Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers'comp. right of exemption'per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp.insurance requited.]
"Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information. 4� _
Insurance Company Name: /10C-r fI11,T> ta1 xf
Policy#or Self-ins.Lic.#: G✓CC.:_1,V. 606 5_0 12 Expiration Date:=?�/
Job Site Address: 7� <?/� ST City/State/Zip:' e"2�,t 6w11=-
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$1;500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a file
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Si ature: Date:
Phone#: a7-,l % 3190 CaC_
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/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:Rdg[tteed Ho`mesfmnrnve rent Cohtcacto ,. s Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M.G.L.c.T52,§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...... ❑
emy"aloe
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(l) 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 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors F-1
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks Siding [0] Other[p]
Brief %Description of Proposed Y�yt ' �� z'� `'" "'`'�`/zd:', .nit a Nc- �K✓�";tc4 ,,1>�SU c:11�+� ����% iGyt
p p C:u,r i3i�t. � �, .yit i7J�c.✓> .��5i?1'+.c. N �..5 �lA2T'�%7�_�S � es,'R�N
Work: Z_ Z2 ., az.l .",zz �rzr
t z �
Alteration of existing bedroom _Yes No Adding new bedroom Yes if No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll <`Shee
sa if"New .House and.or-.�actdI id •ta existir cr�olrsrna�scoinpFefe tk�e fo[fowina:
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: 9` 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-CONTRACT . APPLIES FOR''BUI ING PERMIT
as Owner of the subject
property /
hereby authorize L/5 v /`/ • :Z. /E"/� /�%&
to act on my behalf, in al afters relative to work authorize by thi building permit application.
Signature of Ow'ftW Date
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.
.`s lel
Print Name p
'Signature of Own!rl nt Date
^ r
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
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry ofDeeds?
NO k } DON'T KNOW 'ES
��
IF YES: enter Book Page and/or Document#' �
��
B. Does the site contain u brook, body of water orvvot|unds? NO ��, DON7KNUVV �~� YES
IF YES, has u permit been or need toba obtained from the Conservation Commission?
Needs tobeobtuinad x�� Ob�eioe� � �-� Oatmlssued.
�
«~� �~� '
�
C. Do any signs exist un the prope� ~�y? 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 0 NO 0
IF YES, describe size, type and location:
�
E. Will the construction activity disturb(clearing,grading nr filling)over 1 acre oris it part nfa common plan
that will disturb over 1acre? YEGK } mo ��]
�� �
IF YES,then a Northampton Storm Water Management,Permit from the DPW is required.
+a
Department use onCy
City of Northampton Status of Permit
Building Department CUrI Gut1Dttvewayl'ermit '
12 Main Street Sewev epttc Al
AW
3 r�� R' Om 100 Water/VUe1t AyaiCab�l�ty f ..wr °
Np jhamp n, MA 01060 Two Sets of tructuraC Plans
phoge.t(l,�P;5 40 Fax 413-587-1272 PlotfS�te Plans r
APP OAT- ION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
Th s_section to.bde completed hyoffice<<.
7'7 C MILE s7 =MaP,. Lot. Unitr
OVerfa Y Distr-
you ;
kliiws Distract C&D�stnct
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT'
2.1 Owner of Record:
A T/•1Cp-S L A«C—
Name(Prin Current Mailing Address:7�3,..5'-��r
�`. Telephone
Signature
2.2 Authorized Agent:
44101ro,�1410 cc= c
Name(Print) Current Mailing Address:
-3 5
Signature Telephone
SECTI 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a).Building Permit Fee
2. Electrical (b}Estimated Total Cost of
S `` " -Constructionfrom 6
3. Plumbing elf'G ` Building Permit Fee
4. Mechanical(HVAC) t
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number 33�
This Section For Official Use Only
Building Permit Number. Date ;
_Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
a
File#BP-2008-1032
APPLICANT/CONTACT PERSON John Zieminski
ADDRESS/PHONE 8 WOODRIDGE CIRC HATFIELD (413)247-9014
PROPERTY LOCATION 77 LAKE ST
MAP 17A PARCEL 236 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
"ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction: REMODEL 2ND FLOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 017889
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF_OXMATION 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 Permit DPW Storm Water Management
Demolition Delay
Signature of Building Offi ial 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.
G"10
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CAUL Fon (Zfl N SPELT �S
77 LAKE•ST BP-2008-1032
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-236 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Pern-,ir. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-1032
Project# JS-2008-001532
Est. Cost: $66000.00
Fee: $330.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Grow._ John Zieminski 017889
Lot Size sqjt.j: 11761.20 Owner: MATHERS THOMAS M&KATHLEEN D
Zoning: 'GR B Applicant: John Zieminski
Applicant Address: Phone: Insurance:
8 WOODRIDGE CIRC (413) 247-9014 Workers
Compensation
HATFIELDMA01038 ISSUED ON:51I612008 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL 2ND FLOOR
POST _THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service:/<.,.8 6&W,*4 Meter
n
Rougb:(�"�J-d6Ab( Footings:
Rough: house# Foundation:
Driveway Final:
Final Final:-1 �f
/ / ✓ Rough Frame:;
Gas: Fire euartment Fireplace/Chimney:
n �
Final: Smoke_ �3 '"l �� Final: QK 08-/25/QW- l C
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy c7e- Signature:
Fee Type: Date Paid: Amount:
Building 5/16,/2008 0:00:00 $330.006827
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo