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— DEP T RT1 ENT OF BUILDING INSPECTIONS c c
T 212 Main Street • Municipal B uildinv ' -, . /
INSPECTOR Northampton, MA 01060 --'�
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3A to
act as his/her construction sup: . 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 I
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 regiNations. 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 - inspection (if required) and_ A it 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 ie -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
v The Commonwealth of lassachusetts
\
=, Department of Industrial Accidents
_ , Office of lnvestig a_nons
I 3 ,—,1 600 K ashin�oion Street
r --- / Boston
,c, �, Boston, 3Z4 02111
"c-,� j
�� www.m ass -, , din
Workers' Compensation Insurance Affidavit: Builders / Contractors /EIectricians/PIumbers
Applicant Information Please Print Legibly
Name ( Business /Organizationilndivid t//f'lf9 )fly 6
4-1, /4'1 f -1.
Address: .. / ,mut St
City /State /Zip: #4,..- / e /v,.7' Phone. #: . `T 7 - L C
Are you an employer? Check the appropriate box: Type of project (required):
1. �azn a employer with 4. ❑ I am a general contractor and I
have hired the sub - contractors 6. El
construction
employees (full and/or part- time)_* attached sheet_
2. ❑ I am a sole proprietor or partner-
listed on the a±ta h sh 7. ❑ Remodeling I shin and have no en loy ees These sub - contactors have 8 ❑ Demolition
working for me in any capacity. employees and have workers' ❑
Building addition
i [No wotice s' corny. Ms-zit comp. insurance.+
requi ed] 5. ❑ We are a corporation and its 10.❑ EIect tcaI repairs or additions 3 _ 1 I am a homeowner doing all work officers have exercised their 11 _ ❑ Plumbing repairs or additions
myself. o worke co rift of exemption per MGL
Y comp. 12.0 Roof repairs
insurance required ] t c. 152, § 1(4), and we have no
employees. [_No workers' 13.0 Other
comp. insurance required-]
- 'qty applicant mat cneiu pox f1 must aso lull out the sermon oeiaw showing their workers' coupon policy information-
' Homeowne s 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.anached an additional sheet showing the name of the sub - contractors and rare 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.
Thsurance Company Name: /VT C —
Policy # or Self-ins. Lie. ;r: 44 . 1 cL Sa a 3 O yO / 02 0 CJ 3 Expiration Date: 7// /// O
Job Site Address: 5 Z rily Z-- A tt4 �f'ft..- City /State/Zip: 4/06 u •
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 51 ,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK OILER and a f
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 DLA for insurance coverage verificaion.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
S - area - re: , . — . D //4 ale: G7
Phone #: e ( (7 , iL e
It Official use only. Do not write to this area, to be completed by city or town official
City or T own:
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector
6. Other
Contact Person: Phone .!: ■
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ C�
Name of License Holder : e 01 � / L �J r/ c 6 263
I License Number
Cr / 4 i E fa /
Address / V Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor Not Applicable ❑
d/ -745A0 o/S ? 3
Company Name Registration Number
1 N•'tiI �/
/ Al o/c 7 � 6 //0
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 �1 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 -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
t
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [] Addition El Replacement Windows Alteration(s) 11- Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [DJ Other [E]
Brief Description of Prop9ed _ // / y
Work: / . .✓",, 4 # Til i� �) tc � A- Shit -w ,A4/ .4/4
Alteration of existing bedroom Yes L./No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement 1,...-- Yes No
--�,_
Plans Attached Rollee
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family C/ nt Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms Z -t' 1 -4'7 -7
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
I On r it . / /g '1. //)(, , as Owner of the subject
property .!� r''''. /�
hereby authorize (' (,II C, `A 1't S 1 L
to act on my behalf, in all matters ralathe to work authorized by this building permit application.
7 1,k 71 6 .67
Signat of caner Date
1 ' '�-� '` , 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 per jury.
—
Print Name
-1 /7/5---4.
Signature of Owner /Agent 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 i/ ._ ,..
Frontage t/ L
Setbacks Front
Side L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
narking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 1Q' YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW C) YES C)
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? 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 Q
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 O/
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Departmen use only
/l r � City of Northamp Stags of P e rmit:
•
tl BuildIDepartment Curd Gut/ Dri�reuvay Perm
3 2 12� ff In Street Sewer /SepticAvailability
J o m 100 Water/Well Availability
r. Jatolt MA 01 060 Two Se ts of "Plans
;` phone 41 - 587 -124 Fax 413- 587 -1272 PIoUSite Plans
Other Specify
APP LICATI <� 1S TO CONSTR ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE !W O RMATION
1.1 Property Address: This sec to be complete by office
sci y �; � ��� Map Lot Unit
A/Q II‘) 0/0L 6
Zone Overlay Dist
Elm St D i s tr ict CB Dis trict
SECTION 2 - PROPERTY OWNER /AUTHO AGENT
2.1 Owner of Record:
11)44 � ,7.../z..„ t11(
Telephone
� y S 17 1/ L ' ' L, r e
Name (Print) Curren M fling Add ess: r
K ( • 1 LC - ,l�(�, " v7 A/
Sig
2.2 Author'ze Agent:
Name (Print) ,�� Current MMa iling Address:
Signature Telephone 4.
SECTION 3 - ESTIMATED CONS TRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building s (a) Building 'Permit Fee
3S ()vn
2. Electrical (b) Estimate Total Cost of
—
4- Construction from (6)
3. Plumbing cr41
Bu ilding Perm Fee
5'4)c'41 4. Mechanical (HVAC) —
5. Fire Protection
6. Total = (1
+2,,_3-1..-.
+ 5) � ud � Check mber
Building 5 �� ' 6o� 5. '
T his Section For Officia Use Only
Permit Num ber: Date
Issued:
Signature:
Building Commissioner /Inspector ofi of
Date
Nu
i �
File # BP- 2010 -0518
APPLICANT /CONTACT PERSON ROY OMASTA
ADDRESS /PHONE 21 North St HATFIELD (413) 247 -5666
PROPERTY LOCATION 52 EMILY LN
MAP 18 PARCEL 033 001 ZONE RR(100) / /RI/WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 56r 9t0y
Fee Paid
Typeof Construction: FINISH BASEMENT, ADD BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 006763
3 sets of Plans / Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
_____,--,...7.44 .
Signature of Building Official 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.
a I
. - E"IILY LN BP- 2010 -0518
GIS #: COMMONWEALTH OF MASSACHUSETTS
r 333 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 -2010 -0518
Project # JS -2010- 000731
Est. Cost: $42000.00
Fee: $252.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
ise GrouR ROY OMASTA 006763
Lot Size(sq. It.): 46173.60 Owner: EDMUNDS PATRICK W & MARIE TREMBLAY
Zoning. RR(100)//RI /WP Applicant: ROY OMASTA
AT: 52 EMILY LN
Applicant Address: Phone: Insurance:
21 North St (413) 247 -5666 Workers Compensation
HATFIELDMA01038 ISSUED ON:11/16/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: FINISH BASEMENT, ADD BATH
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 11/16/2009 0:00:00 $252.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
52 EMILY LN BP -2010 -0518
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18 - 033 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- 2010 -0518
Project # JS- 2010- 000731
Est. Cost: $42000.00
Fee: $252.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROY OMASTA 006763
Lot Size(sq. ft.): 46173.60 Owner: EDMUNDS PATRICK W & MARIE TREMBLAY
Zoning :. RR(100)//RI/WP ___ Applicant: ROY OMASTA
AT: 52 EMI L Y LN
Applicant Address: Phone: Insurance:
21 North St (413, 247 -5666 Workers Compensation
HATFIELDMA01038 ISSUED ON :11/16/2009 0 :00 :00
TO PERFORM THE FOLLOWING WORK: FINISH BASEMENT, ADD BATH
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing e Inspector of Wiring D.P.W. Building Inspector
Underground: 0 Service: Meter:
Footings:
Rough:A1 —n 1 * - L #/`,: /
Rough: -0 7 House # Foundation:
OLl' Driveway Final:
Final: 3,10-1» LL Final: 3J/24 �® C'1{ r 4/4'
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
((ch.! t c��'I
Rough: Oil: Insulation: l
Final: Smoke: Final: OJ 311210 IOM( S
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAJIpN OF
ANY OF ITS RULES AND REGULATIONS.
1
Certificate of Occupancy( - ' a te Signature:
FeeType: Date Paid: Amount:
Building 11/16/2009 0:00:00 $252.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
52 EMILY LN BP- 2010 -0011
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18 - 033 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- 2010 -0011
Project # JS- 2010- 000013
Est. Cost: $16250.00
Fee: $96.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: , Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 46173.60 Owner: EDMUNDS PATRICK W & MARIE TREMBLAY
Zoning: RR(100,2//IU/WP Applicant: EDMUNDS PATRICK W & MARIE TREMBLAY
Jas. ,, '77.:!...‘t .__.
Applicant Address: Phone: Insurance:
52 EMILY LN
N O RT HAM PTO N MAO 1060 ISSUED ON: 7/8/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL BATHROOM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
v k
Rough:
Footings:
j�. i� p Rough: House # Foundation:
/ /g/ 9
Driveway Final:
Final: i Vi ( final: q-/6 — (5
A phi Rough Frame: �k 07 i t o i i j
Gas: Fire Department Fireplace /Chimney:
cor 0. a9
Gds
Rough: Oil: Insulation:
/ i /
Final: Smoke: Final: , ; � 2c4
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATJONS. 77
Certificate of Occupancy .�v
Y signature: ,
FeeType: Date Paid: Amount:
Building 7/8/2009 0:00:00 $96.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo