17D-019 (7) -ity of Warthanytou
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DEPARTMENT OF BUILDLNIG INSPECTIONS /=
INSPECTOR
'212 Main Street • Municipal Building
Northampton,Mil 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to
act as hds/her construction sup(:: .- 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 farm -
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 r',egulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footing's (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 prope permits and inspections are
made
understand the above.
(Home owner/resident's signature requ sting exemptio
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date w (7
Address of work
location
-
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Orf(laillp!oil
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4 DEPAR7ME1J7 OP DUILDI),,)G INSPPGTIOIIIS -
212 Alain Strcct ' Municipal Building
j Northampton, Mass- 01060
`tr'O MCC IZ'S COi\ZI'ENSATI ON MSURANCF AFTIDr1 VIT
I
(]i cons n'Jperml tfcc)
�tlJ a principal place of businessfresidence at: — - -
(phone..
(slrcs.t/ci ty/natda p)
do hereby certify, under the puns and penalties of pcf3ury, :hat
( } I am an employer providing the followine!workcr's cotnocns-n:Jon covervge for Illy
emplovecs wortaig on tills job.
(t:szu-aB=.Con (r:-pirvon Dz�.)
( ) I an a sole proprietor, general cooti-ac-Lor or homeow'Der (c c:e one) and Dave hired
the coauaciors listed below who have the fotlo%vino workers c-0 oen�aon policies:
(i+fln1C Oi Coatncior) Gn--umnc:; Colnoanyili c icy (Expif'JG^? bete)
- (Namc of Concaaor) (tnszrancc ComoantivPoUm, Ntncrr) (-Expo i.ion DLffe)
(Name of Coaaaaa,) (Insurance CcmpanyfPaUcy Nwnbes) (Expimaon Daic)
(Namc of Contractor) (Iasuranc-c Company/Policy Numbs) (E��irdoa Dau) .
(aIIa�addi�ocal dca,irncocz.r:y-to a�c!ucz infort7ii oa per"�to.iJ ma7-to:-s) -
O I am a sole proprietor and Lave no one working for me.
I am.a home owner perforramc, all the work myself.
NOTE.plesc be tw-im 0-NJ Jc hcmr_o vom wt�o c=ploy per- co cis 4 �raaa or rcpau wank oa.d..c.[L^Z of
aot Moct lb-n dzroc-=al is winch the bomcov r=do or oo tlx a` zPp utcn tbceo tz oot C= rlly arrd-nt to be
=Ploy---d (GU152-=1(5)) :,oplio.6oa by n homeo-D=fcr e F _cc puma c=y cNi& c LL'C
Iegal its^„of as eployee underdio Warhol.Corapamalio Aa-
[undesriad tha a Dopy of thi.=aL, tn,ry bo foe-++urd.od to ibo pepo.rtmm¢of OQ oe of 6-u foc th. _
cov=-ab'e veil-elioa,:)d t1Lt Utzc to to=c 1_ovcr se undo=Ctioa 23A of MOL 152 can I-d to the carxu -cf ci-;o t>-""-
eoa;.i5ing of a rinc or up to S 1 500.00 aadler j= iyoo of up to Doc r r end avi]P=..hio in be form of a Step wuric Ord,-- and' - -
rtna
0(5 100.00.day epiwa mr-
For only
pertmt Numb-
1.42 p"—_ Lot
Signature ofLia L-CcjFcaniucc -� S
SECTION 8-CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9` Reg19fdf,64 Tome lmarovemerr Contractor Not Applicable ❑
Company Name
Registration Num er - -
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE:AFFIDAWT(M�G.L.c.152,§25C(fi))
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
structures.A person who constructs more than one home in 4 two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a farm acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building hermit.
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 u�nes s onsibility for compliance with the State Building Code,City of
Northampton Ordinances,State Loc o aws d Stat assachusetts General Laws Annotated.
Homeowner Signature
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SECTION 5-:DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [_� Addition ❑ Replacemen down Alteration(s) ® Roofing
Or ors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [® Siding[WJ Other[O]
Brief Description of Proposed
Work:�;'g Si�..�..�,
Alteration of existing bedroom Yes O No Adding new bedroom Yes )c No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa (f I�eW House and or acidi#ion to eic�stincfiO.usincr;:corpfefe=fh�foF�civriincl:
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 l 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
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
-----------------
p
I, �. \ t�=jC'� 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
Signature of Owner/Agent Date
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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: R:=
Rear
Building Height
Bldg. Square Footage —1 %
Open Space Footage ^_ % --
(Lot area minus bldg&paved E
parking)
#of Parking Spaces
Fill: ��
(volume&Location) '
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
N0 0 DONT KNOW X>t YES Q
IF YES, date issued:.
IF YES: Was the permit recorded at the Registry of Deeds?
NO A>1 DON'T KNOW 0 YES 0
IF YES: enter Book ' Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW Q YES Q
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 0 NO
i
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 I
IF YES, describe size, type and location: t
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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of NortF arnpton a
I, E(� q department CtrsC ' wad Perrtt
- C E 1 ain Street s wens �I
om 100 fifer evafiaT .
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i 11 n,�rth0I can; MA 01060 T �etsStrccraktan , ; <
OCT phtorre `'i'i458 - '0 Fax 413-587-1272 PCotiSGt�e ?Carls _
! Otter"Speefiy� � r
APPC 14 GQI RUCT,AL*ER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION,1 -SITE,INFORMATION
This section to be com leted b ffi
oce
1.1 Prove rty Address: P Y
Lot Unit
Zone Overlay Distnct
E uD[strict CB D�str►ct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: // 1
Z-\ �T �EC�t� 6S `JO�sJO ls�vt�T� I, yIJ�,.ovJ i � c 10 S�o
Name(Print) -_. Current M ing ddress:
�3�5`l+-$`\%$
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION`3-ESTIMATED COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building *, c�by (a)Building Permit Fee
2. Electrical (b}Estimated Total Cost of
c Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) CDC) Gheck Number
This Section For Official Use Only
.Date
Building'Permit Number Issued:
Signature:
i
Building Commissionerllnspectorof Buildings Date
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117 STRAW AVE BP-2005-0450
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D 019 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv:windows replaced BUILDING PERMIT
Permit# BP-2005-0450
Project# JS-2005-0558
Est. Cost: $6000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 19819.80 Owner: PIETRAS MICHAEL
Zoning:URB Applicant: PIETRAS MICHAEL
AT. 117 STRAW AVE
Applicant Address: Phone: Insurance:
P O BOX 11 (413) 583-5254 ()
LUDLOWMA01056 ISSUED ON.10/18104 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR SIDING, INSTALL REPLACEMENT
WINDOWS & DOOR
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 Sienature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 10/18/04 0:00:00 816 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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117 STRAW AVE BP-2005-0450
GIS#: r
COMMONWEAL 1°H OF MASSACHUSETTS
Map:Block: 17D-019 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGI&TERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:windows replaced BUILDING PERMIT
Permit# BP-2005-0450
Project# JS-2005-0558
Est.Cost: $6000.00
Fee: $25.00 PERMISSION IS HERE,BY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sn. ft.): 19819.80 Owner. PIETRAS MICHAEL
7�n3 _I1 cii �R731/lSa/iL. ^f� e:s�.:r by �`
AT. 117 STRAW AVE
Applicant Address: Phone: Ins ce: J7�
P.0 BOX 11 '
(413) 583-52545,E
LUDLOWMA01056 ISSUED ON:10 118104 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR SIDING,, INSTALL REPLACEMENTS
WINDOWS & DOOR
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: �k 3"a27-43 ''� ✓
THIS PERMIT MAY BE REVOKED BY THE CI OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occunancy si nature: l
FeeTvve: Receipt No: Date Paid: Check No: Amount:
Building 10/18/04 0:00:00 816 $25.00
212 Main Street,Phone(413)587-1210,Fax:(413)587-1272
Building Commissioner-Anthony Patillo