29-018 assac u4 tts 7 - department of Public Saret■
Board of Budding Regulations and Standards
Construction Supervisor License
License: CS 100515
Restricted to: 00 .
TIMOTHY LUCE
PO BOX 14
LEEDS, MA 01053
Expiration: 7/15/2012
#### er Tr#: 100515
gge eamosevemeaa +1,..,agoodounal
Itaard aflutter% leadations and Standards
License or mistral*, valid for hadvidal lase only
Nom annwamarr CONTRACTOR Wore the expkatian date. ff found return to
Board of BOW* Regulations and Standards
Regkela0011C 1492a6
One Ashburton flare Itaa 1301
Extdratiolc 12f154009 T,$ 263459
Type: Individual Boston, Ma. 921{91
TIMOTHY si WCS
TIMOTHY UXE _
in ALMON RD.
LEEDS, MA 01053 1.1 5 - ‘‘ Admithitrator
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 person(s) who seek to use
the home owner exemption, to act as their or 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
- - - -- - - -- — per -mits- in-conjunction.to_the building
p ermit ued,_and_ 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.
Address of work
location
M • t M
The Commonwealth of Massachusetts
� � Department of Industrial Accidents
t. =" i.. g r 1 Office of Investigations
® ; 600 Washington Street
0 cEf= Boston, MA 02111
W . ' www.mass gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information 1 Please Print Leg
Name (Business/Organizatio , idividual - , `--c---
Address: V C 1 . 4 X , i L -
City/State/Zip: 1 ) / 1 / V O/O S '? Phone #: fii3 - 5S - f - 7J
Are you an employer? Check the appropriate box: Type of project (required): /'
1. ❑ I am a employer with 4.. 0 I am a general contractor and I
�--, �e Ioyees (full and/or part- time).* have hired the sub- contractors 6. ❑New construction
2. I'l I am a sole proprietor or partner- Listed on the attached sheet 7_ Remodeling
ship and have . no eloyees These sub - contractors have. g. 0 Deyioliuon
working for me m any capacity. enailoyees and have workers' 9. 0 Bufciing addition.
. ns�anl e.
No workers' corm: insurance c i
requirecLj 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
q ] 9 eer hay is_ed their
3. [Q am�o-meowaer d g a �ver — Q Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12. oof repairs
insurance required:] t • c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.}
*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.
: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 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 fne
of up to $250.00 a day against the violator. rye advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certify under the pains and penalties of that the information n provided :ahoy - _is_true_aniLcorrect___ _
Si .. = °.i i i _ ! .
Phone #: y(3 32 47800 -
f . Official use only. D wale iin this arrea, to be completed by cixy or &WI
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Cterk 4. Electrical Inspector 5. PIumbing Inspector__ _
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: j Not Applicable ❑
Name of License Holder : r L , �- C.5 /6051C
License Number
P o ` 3c-- H Le, -3 }AA 0 / 0 ,5 3 1 i(, ` /2
Address t Expiration Date
V3 3 ?IC°
ignature Telephone
S. Registere "d. Home. Improvement Contractor . ., „;;. • x.. , rt _ .. :A, ,i.r.. , ..i Not Applicable ❑
1iw.. ..�• L,..p iwz.88
Company Nam Registration Number
Sec .,.12_ to /}' it//6714-X),
Address A ^ / // 7”
Expiration e
I Z ✓ ter- - L 2.1. S 4 £ d s Telephone7(3 30-
-
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 buiidin permit.
Signed Affidavit Attached Yes No ❑
Zl� p I ' m � emu
The_current_exemption for "homeow_ners" 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/ 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
— r - - rat - Laws- Annotated.
`'o _ _ ampton *1-s a e • � __ w -- , � . ,� .� � °
Homeowner Signature
1
-.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) JJ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [D Siding [o] Other [ID]
Brief Des (ion f Pro ose �'j, ,l �,,ao ` r f
Work: & `� p ( } y LO J "'a ►"�) 2 l l y r5 c>, � G ' 1 s r
C�i�.� = � .�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. lf. Newr:house'`.and oT addi lion.Ito'.exist nci io lslncl, cottmal&e fhe foitownnq:
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
eer , as Owner of the subject
property
hereby authorize .
to act on my • - • .If, in all matte ative to work authorized by this building permit application.
Signature of 0 Date
1, ( y � l,A" � �l 6C e as Owner /Authorized
Agent hereby declafe 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
71
Sigrratur- of Ow.- gent late
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.
Rear
Building Height
Square Footage
Open Space Footage
(Lot area minus bldg & paved - n
parking)
# of Parking Spaces
Fill:
(volume & Location) _, a
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW Q YES Q
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book Page i and /or Document # i
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location:
D: -Areea - ere any proposes changes to or a rttons signs intended of the property ? YES Q 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 0 NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton Statics o1" Pettit ;
Building Department c6l '''q:**-,,...- l i v -- � � . i .,
212 Main Street se +e /Septt tiabt ' _ ;y 1 >
Room 100 > ,� ��( ' �4,� ,� iT a v a
Northampton, MA 01060 .., e � f c t a ts � � - _ k
T, -- p hone 413- 58771240 Fax 413- 587 -1272 Plait) ads g ; A 4 � 4fg�,
' ;
Y
APPLICATION TO CONSTR ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
1 10 /i ku!ry lv /�
P' Map Lot Unit
Zone Overlay District
EImSt. ° CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Pr;;,. ` Curren �il Add -
fW�ia „.1 , 4, Telephone
Signature
2.2 Autho : /4C• -
V- -J 3 . 1,.E - � -- PO t c -v- )q L-044(15 (� clash
Na t) Current Mailing Address:
` y/ 3 33'1 7
- Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 4 oe 0 - (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 35" 40_1. 9it 6. Total = (1 + 2 + 3 + 4 + 5) � Check Number / /Q
_ — ,
_ This Section Forbfficial se Oniy
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings - - - - Date
lit' tit BP-2010-0375
GIS #: COMMONWEALTH OF MASSACHUSETTS
lap :Block: 29 - 018 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 -0375
Project # JS- 2010 - 000497
Est. Cost: $7000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY J LUCE 100515
Lot Size(sq. ft.): 14941 .08 Owner: KEEFE JAMES J & YVONNE C
Zoning: URA(100) / /WSP Applicant: TIMOTHY J LUCE
AT: 40 HICKORY DR
Applicant Address: Phone: Insurance:
P 0 BOX 14 (413) 387 -9800
LEEDSMA01053 ISSUED ON:10/6/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: STRIP & SHINGLE ROOF
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 10/6/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo