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City of Northampton
Mas sachusetts
t _ ' IV: '� DEPARTMENT OF BUILDING INSPECTIONS a?
212 Main Street • Municipal Building J 1"4:;" i
Northampton, MA 01060 �
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his /her
construction supervisor. 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 /footing kbefore 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
The Commonwealth of Massachusetts
``' `•- Department of Industrial Accidents
Office of Investigations
600 Washington Street
-;: Boston, MA 02111
tor www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business / Organization /Individual): "5/ -1l —
Address:
i� '- .
City /State /Zip: , Gilp27 Phone #: ��' ,5 �7
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. New construction
2. I am a sole proprietor or partner - listed on the attached sheet. 7. ❑ Remodeling
These sub - contractors have
ship and have no employees 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. n Building addition
[No workers' comp. insurance comp. insurance.$
required.] . n We are a corporation and its 10.0 Electrical repairs or additions
] f
officers have exercised 11. Plumbing repairs ❑ I am a homeowner doing all work h id their ❑ g epairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. ❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors 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.
Insurance Company Name: _
Policy # or Self -ins. Lic. #: Expiration Date:
Job 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 $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
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 cer ' u er the ai s a lties o erjury that the information provided above is tr and correct.
Signature: ' 0' Date:
Phone #: -- 7g` � ' 2 ? 2
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 H 7. Building Department 3, City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other •
Contact Person: Phone #:
r
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement 'ndows Alteration(s) n Roofing 1 1
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [O] Other [O]
40,42) ,' T,evf/ l U /T
Brief Description of Proposed
Work:iU,�jLGbL D/
Alteration of existing bedroom Yes [/No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes o
Plans Attached Roll - Sheet
6a .lf. (ew:house.and or addition to existing housing ;completeThe ffollowing:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: /0 Number of Bathrooms
c. Is there a garage attached? /lc,
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? 3
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 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? 2--- Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION -TO BE COMPLETED WHEN , = t r ry
OWNERS AGENT OR CONTRACTOR.APPLIES-FOR BUILDING PERMIT"
I, Ai4reft— 5.r' L coAia /fir` f , as Owner of the subject
property
hereby authorize L.1 ✓c� �:�fO't —
to act on my behalf, in a matters relative to work authorize• by this building permit application.
• / '—
Signature Owner Of Date 4:9
0 " - , as Owner /Authorized
Agent here• declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Sign- unde the %. -nd penalties . . erjury.
r
Print N-J
Signature oLY er /Agent .ate
SECTIONS CONSTRUCTION SERVICES
8.1 Licensed Construction Superv'sor: Not Applicable ❑
Name of License Holder : s � 5Y6` < le
License Num er
/� /0,07e,9. 7 /0 7/ K.,
Addres T 0 ,/:3..s3 , -71.,0e9 } Expiration Date
Signature a ephone
WA—Carere ome m • rovement<Gontttactor 7 1 x , f:`. J Not Applicable ❑
Compan Name y � , Registgratio NNuu ber
�/ i' ,/ / ir-se r Lgr .� -�'i Jl'�� i�'l oze -� 7
Address Expiration Date
f/3 ffri s , 7� (i Telephone lv��v?/
SECTION 10 WORKERS' COMPENSATION IN 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 buildin emiit.
Signed Affidavit Attached Yes No ❑
. i( TIl " .. wn ltelnPtiOn
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 -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
J
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Inco pleteinformation
Existing Proposed Require by 'Zoning
This col to be fi
Buildin ep ent t V s je
Lot Size I ` i a' t
Frontage ` "
Setbacks Front , # 1
Side L:' R: L:' . ; R: {
Rear I
I
Building Height l I" p
Bldg. Square Footage a 1 I_ I % I
Open Space Footage
(Lot area minus bldg & paved i I ( I
parking)
i 3
# of Parking Spaces
Fill: r ___ __ _ I
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 040 YES 0
IF YES, date issued::
i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book j I Page : and /or Document #1 !
B. Does the site contain a brook, body of water or wetlands? NO 4) DONT KNOW YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued: i
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
's
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: r
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 0 NO O
4.
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
i
De9rtrnerat use only
ter e c) ity of Northampton S tus,, Per it
uilding Department Cur• Ci Dr4
d , 212 Main Street Se�c la�gtlty '0�� �K.
9 Room 100 UUa eeliPyatlabtt ��
ort mpton, MA 01060 Two Se so S r u p 1
;.� :7 - 1240 Fax 413 587 - 1272 (;1® SA eiP. '
sv . v 1 L1 ecil
PPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
This section to be completed by office
1.1 Property Address: ���.-
s.5 %� / h 4
~� GyG�1 ', �
..! e/2_7 K/� /W, dld,e
Etm St District ? ` ` ° CB District - `" `
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT .. .
2.1 Owner of Record:
Name (Print) Current Mailing Address:
r 1';71 -- Telephone r,
signature r7 - ie4
2.2 Authorized Agent:
ae-454 ate/S-02772eir 5? ZA '2; '1.6
Name (P ' t) Current Mailing Address:
.. ,
/ %" -7r '
Signature f Telephone
SECTION 3 ==ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only _,
completed by permit applicant
1. Building `44r e ` (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of '
Construction from 46)
3. Plumbing . Building Permit Fee:
4. Mechanical (HVAC)
5. Fire Protection _
6. Total = (1 + 2 + 3 + 4+5) Check Number j
This •Section For Official Use Only
Date .
Building Permit Number:
Issued. .
Signature:
Building Commissioner /Inspector of Buildings Date
•
File # BP- 2012 -0271
APPLICANT /CONTACT PERSON CORBEIL CONSTRUCTION
ADDRESS/PHONE 148 PARK ST EASTHAMPTON (413) 527 -9286
PROPERTY LOCATION 50 HAWLEY ST - UNIT 4
MAP 32A PARCEL 168 000 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid � vil
Buildin Permit Filled out �� _ _ 4 -
Fee Paid i ' _ _ soak'
T 0 eof Construction: INSTALL 2ND FLR PORCH WINDOWS
New Construction I —
Non Structural interior renovations - si:!ALrA'Et! • r j
Addition to Existing !`
� ,,� _
Accesso Structure y ` f _� ! � ?��� :' % "IWI'•a ,�'# � -
`
Buildin. Plans Included:
Owner/ Statement or License 059611
3 sets of Plans / Plot Plan
THE FOL ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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
", lay r„...„..
Si of B ild' g ff ' al 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.
■
V
50 HAWLEY ST - UNIT 4 BP- 2012 -0271
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 168 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit # BP- 2012 -0271
Project # JS- 2012- 000438
Est. Cost: $2500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CORBEIL CONSTRUCTION 059611
Lot Size(sq. ft.): Owner: STECKERT JOHN & FOSTER KAREN
Zoning: Applicant: CORBEIL CONSTRUCTION
AT: 50 HAWLEY ST - UNIT 4
Applicant Address: Phone: Insurance:
148 PARK ST (413) 527 -9286
EASTHAMPTONMA01027 -2162 ISSUED ON:9/22/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 2ND FLR PORCH WINDOWS
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 9/22/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner