38B-178 . a
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CVR 108.14 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 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 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 penults and inspections are
made
1, 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 IlassacJ userrs
7;=.1 Deparrrnent of Industrial 4cciienrs
Office of Inresti arzohs
_ - 600 iTashin won Street
— — Boston, !11.4 02111
>tiw. mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /EIectricians /Plrumbers
Applicant Information ) PIease Print Leo
Name (?usiness/Orcani aion,Individuai): gCctc_ 1.._(. 3f'
Forkv\-- 600(---,(
City/State/Zit): fr > t 1 1 il, 1, Phone ,,=: '((3
Are you an employer? Check the appropriate box: Type of project (required): I
4. I am a general contactor and I
1. El am a employer with � 6. ❑ New construction
employees (full and/or pan- time).*
have hired the sub - contractors
2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodel fig
ship and have no employees These sub -coot actors have 8. 7 Demolition
i working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. We are a corpora ion and its 10. ❑Elect ical repairs or additions
3. El am a homeowner doing all work officers have exercised their 11.,D Plumbing repairs or additions
myself o workers' comp. right of exemption per MGL
12.❑ Roof repairs
insurance required.] ' c. 1 2, § 1(4), and we have no 13. Other i fra('C r C
employees. [No workers'
comp. insurance required.]
Any applicant that checks box =1 must aiso 51l out the section below showing their workers' compensation policy inforrration.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Conn that check this box must attached an additional sheet showing the narr of the sub - contractors and stare whether or not those entities have
employees. tf the sub - contractors have errroloyees, 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
info= anon.
Insurance Company Name:
Policy 4 or Self- -ins. Lic. 4: 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 51,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigadons of the DLA for insurance coverage verification.
I do hereby certify under the pains and penalties o perjury that the information provided above is true and correct.
a'
S re . att: e. : / j• - ,�,
� � Date: L C
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f
Phone 4: • 1 ` 4:
i
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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): i
1. Beard of Health 2. Building Department 3. City Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
1 6. Other
i . i
I, Contact Person: Phone 4:
•
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supenriisor: Not Applicable ❑
Name of License Holder : 4-5 j?
License Number
�- Do y , P , ° petheow-, MPf C(C l3
Address ! Expiration a gi
•
Sig .ture 4 Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
a
G. 0 1G 6t�� gI '& 41 C a3 ?o7
Company Name 1 Registration Number
Address / / Expiratio ate
Telephone 1-53 ( V
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 ermit.
Signed Affidavit Attached Yes 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 buildinu 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 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Ej Siding [D] Other [0]
Brief : EQ ' _ ti S Prop G►^ t'T W1..4%40 t . li'� y . e-,1 L 1411 CeCt. (
w` .�
Work: EQ.' � r
yr,.
Alteration of existing bedroom Yes � No Adding new bedroom Yes f No / �({�'-r, ' ,
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
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 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
1, , .'2' L; i t �� , - as Owner of the subject
property i J
hereby authorize r t E.it- LI
to act onjny behalf, in all matters relative to work thorized by this building permit application.
' '''';',/ t I 4
/) L9'� -- - J i
I. --1(
Signeure of Owne Date /{
1 , ti Cli- ( 14 it , as Owner uthorized
gent reby declare tha he 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. Ly-t-
Pctt
Print Name
Signa:4re of Owner /Agent / Date
K
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
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW Qf YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT 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 t DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 e
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, . ation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
;A 212 Main Street Sewer /Septic Availability
V
Room 100 Water/Well Availability
Northampton, MA 01060 • Two Sets of Structural Plans
phone 413- 587 -1240 Fax 413- t - 2'2 Plot/Site Plans
4 ° Other Specify
APPLICATION TO CONSTRUCT, AL .Y • R, RENO AT • R DEMOLISH A ONE OR TWO FAMILY DWELLING n
SECTION 1 - SITE INFORMATION 0 �4('
,, This section to be completed by office
1.1 Property Address:
d Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: n
I �S
A_ i '� o4 � /... ? v �,it✓'{ t C i ..� , , < 1f ' v
Cur ' ' , Cit , '✓ ; %: / i i,- -
/
Name (Print) t Current Mailing Address ,.
.7 // r a (( ,, ,, 41 - ' 1 . ) L , ` J /C L__.- 1 , . f t / . Telephone
Signature t
2.2 Authorized Age
p � l, 151 AC (3O/` pe-,�� Pdta mg-
Name (Print) / Current Mailing A dress: Mr t6
Signature t / Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
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 + 5) 45 / e Q f), cv Check Number dj /a 44f
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
;1 id h
C --
File # BP- 2011 -0700
APPLICANT/CONTACT PERSON RICK LIGHT
LE- mES5AC�
ADDRESS /PHONE 25 BOYDEN RD PELHAM (413) 253 -9492 N EE) $E L GOI.amN BASS
PROPERTY LOCATION 11 FORT ST $' U' fO Pa") Ml) EC0
MAP 38B PARCEL 178 001 ZONE URB(100)/
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:_ADD LOLLY COLUMN IN CELLAR, RESUPPORT 2 INTERIOR BEAMS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 056457
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
i 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
-
3/AbA
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.
11 FORT ST BP-2011-0700
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B -178 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Non structural interior renovations BUILDING PERMIT
Permit # BP- 2011 -0700
Project # JS- 2011- 001151
Est. Cost: $5000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICK LIGHT 056457
Lot Size(sq. ft.): 4051.08 Owner: ARNY LIBBY C
Zoning: URB(100)/ Applicant: RICK LIGHT
AT: 11 FORT ST
Applicant Address: Phone: Insurance:
25 BOYDEN RD (413) 253 -9492
PELHAMMA01002 ISSUED ON:3/2/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD LOLLY COLUMN IN CELLAR, RESUPPORT
2 INTERIOR BEAMS
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 3/2/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner