38B-089 City of Northampton .
�o M ' � S - S, •
Massachusetts w �' �"
F rot } t;f •W
(Pt' DEPARTMENT OF BUILDING INSPECTIONS
t 212 Main Street • Municipal Building ..* �S`
\7 Northampton, MA 01060 �S . V - D 'Sh :��
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 /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 permits
and inspec i.ns are mad-
,/ 7
1, ' - ,
c understand the above.
( •me owner /re id:- 't' signature requesting exemption)
I will call to schedule all equired building inspections necessary for the building permit issued to me.
Date ?-/ 3 1 / 2- 0 I %--
Address of work location 4t- q L 1 l'1 i .)
N )......- rA- k.... Ylo■ - 76 ,A 11 19 0 / 0 ‘ e
•
The Commonwealth of Massachusetts
, Department of Industrial Accidents
Office of Investigations
, _'" 600 Washington Street ,
,. -e :-- 1 Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): G PdZ --t- f t --(- -` M 6 L--E 1 _
Address: '4 6 V-`1 vv k-n) "P--9
City /State /Zip: Nis a-tcivim Q n r "" Phone #: U V 1 - S 9 ' - ° 1-(3 \
Are you an employer? Check the appropriate box: Type of project (required):
1.E I am a employer with 4. I 1 I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6 New constriction
listed on the attached sheet. 7. n Remodeling
2.E I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. n Demolition
working for me in any capacity. employees and have workers' 9. n Building addition
[No workers' comp. insurance comp. insurance.
/ equired.J 5. n We are a corporation and its 10.n Electrical repairs or additions
am a homeowner doing all work officers have exercised their 11.n Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.1 1 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.n 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.
1 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.
Ido hereby certify u er the pains a , ,e , ties ofperjury that the information provided above is true and correct
Si• ature: / .r
Pit AIIII■ A/ Date: Z.—
Phone #.: 6 1 7 - 5--- ` ?-Q l
■
1 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 B r`1 of Health 7 B D i (itv /Tnwn Clerk 4. Electrical Inspector 5- Plumbing Inspector
6. Other •
Contact Person: Phone #: _
.,
SECTION 8 - CONSTRUCTION SERVICES
t,
8.1 Licensed Construction Supervisor: Not Applicable ID
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9: Regiite ed Ho ire' amprove'ment ContractoF, : .w. : .; .r, 1,s t w ,, , mm , Not Not Applicable ❑
Company Name - . istration Number
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 ❑ No ❑
1 . 1 ::Home .O
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 ocal Zoning aws , d State of Massachusetts General Laws Annotated.
Homeowner Signature / / ,
,
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) k, ,
--
New House r7 Addition ❑ Replacement Windows Alteration(s) : I Roofing I
Or Doors \�
Accessory Bldg. n Demolition ❑ New Signs [El] Decks [p Siding [O] Other [0]
Brief Description of Proposed
Work: c'L.4kLI 5 l'D`ts3 Cs-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa if New fib "use and o r ; addition to exiting - hous nq complete thefollowi nq:
a. Use of building : One .mily Two Family Other
b. Number of rooms in each fame 'nit: 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? ' -places or Woodstoves Number of each '
g. Energy Conservation Compliance. Massch- k Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of w- ands? Yes No. Is construction ithin 100 yr. floodplain Yes No
j. Depth of basement or cella 'oor 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 CONTRACTORi;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 •uildin• : - mit application.
Signature of Owner Date
C- ' r lit, 5 1p , . Owner - , thorized
Agent hereby declare that t state information on the foregoing application are true and accurate, to th- •est • y knowledge
and belief.
Signed under the pains and p nalties of perjury .
Print Name
1`
Z.____ Date
Signature of Qw_ar /Aunt
,
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by '
This column to be filled in by „ .
Building Department Ai ,. {
Lot Size — _ .._ _ _ _
Frontage ___ _
Setbacks Front ___
__
Side L: R :.__._._ L. _® __.... R:_... __. ._
Rear i __;
Building Height
Bldg. Square Footage _ " °" A� __
{
Open Space ootage
(Lot area minus bldg & paved . _ —
parking)
I
# of Parking Spaces
Fill: —_ . ,_ __
(volume & Location) - A. Has a Special Permit/Variance/Finding ever been issued for /on the site?
NO 0 D• .T KNOW 0 YES 0
IF YES, date issued::
IF YES: Was the permit recorded . the Registry of Deeds?
NO 0 DONT KNO ■ 0 YES 0
IF YES: enter Book Pager 1 and /or Document #
B. Does the site contain a brook, body of water or -tland NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtai -. .m the Conservation Commission?
Needs to be obtained O. ained lb , Date Issued:
C. Do any signs exist on the prope ? YES 0 No
IF YES, describe size, . .e and location:
D. Are there any propdsed changes to or additions of signs intended for the.property ? YES 0 NO 0
.
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
• it
Department use only.
City of Northampton RE Sta of Permit
...._. � E' ' 'i v psi k s, d� # r R
Building Departen Ottrb •Cut/Drlveway Permits z
I 212 Main Str et .' Sewer /SepticAvallabihty
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Room 10(� `�`��- � � � � � � � _ � ���
; Northampton, MA 01�D60 T o S s afStru Pl -r 4� �'
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L. i: OF Buis.'. , ,PECTIC 'a
r "�- =� , ; ,AOne 13 587 -1240 Fax 4�1,272 PIot�SifePlans�
—
Other peci
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APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
Th is section to be completed by office
1.1 Property Address:
Lt r� �� q 2h ;Map Lot Unit
tU 0 (L�"t,A -Ps(Vn t"2 I V iJ i M A-
2 on e_'z O verlay Dis trict
EIrn'St. District ` CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
k-- Y3 t L - L ,P.1 6 -S L. E`
Name (Pr Current Mailing Address:
f
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature 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) Estim Total Cost of
Construction from (6)
3. Plumbing Buildin Permit Fee
4. Mechanical (HVAC) a
5. Fire Protection
..�'6. Total = (1 +2 +3 +4 +5) S, boa. Op
' it Check Number - "
This Section For Official Use Only
�, Da
Building Permit Number: Issued:
ii/.............0L j
Signature: _ - _, /
Building Commissioner /Inspector of Buildings Date
49 LYMAN RD BP-2013-0121
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B - 089 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category vinyl siding • BUILDING PERMIT
Permit # BP- 2013 -0121
Project # JS- 2013- 000194
Est. Cost: $8000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10062.36 Owner: BILLINGSLEY EARL T & MARIA DE LA VEGA
Zoning: URB(100)/ Applicant: BILLINGSLEY EARL T & MARIA DE LA VEGA
AT: 49 LYMAN RD
Applicant Address: Phone: Insurance:
49 LYMAN RD
NORTHAMPTONMA01060 ISSUED ON:8/1/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE SIDING
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 8/1/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587-1240, Fax: (413) 587 -1272
Louis Hasbrouck— Building Commissioner