42-078 (4) 9 Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supers isor Specialt- " a„
License: CSSL-101196 1
DALE A SMITH zf' , (. '
26 COLLEGE VIEW HEIG S
SOUTH HADLEY MA 010'
J..G,.. l)I Is
Expiration
Commissioner 07/07/2014
a M
City of Northampton
0. H
j„ Massachusetts w'� ' f{,
ok'z" rG1
€,> " v, DEPARTMENT OF BUILDING INSPECTIONS ( " 1.._!
„,,....,. . .., ,,,,
212 Main Street • Municipal Building -.6:t.', �~
Northampton, MA 01060 �s1 ‘'.
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
fie/she relides or intends to be, a one two family dwelling, attached or detached structures
accessory to such use and/or farm struct es. A person who constructs more than one home in a two-
year period - all not be considered a horn owner."
The building d-•artment for the City of NorthaNiwton wants any person(s)who seek to use the home
owner exemptio to act as their own constructs n supervisor, to be aware that by doing so you
become respon-'ble for compliance with stat building codes and regulations. The inspection
process requires t :t the building department be c lied to inspect work at various stages, which include
foundation/footinq (before backfill), sonotube les (before pour), a rough building inspection
(before work is con, ealed), insulation inspection if required) and a final building inspection.
The building departme t requires these inspections be re the work is concealed, failure to secure
these inspections can esult in failure to obtain a ce ificate of occupancy until the work can be
inspected.
If the homeowner hires oth.r trades to perform work(elect ical, plumbing & gas) the homeowner will be
responsible to make sure th. the trades hired secure their proper permits in conjunction to the building
permit issued, and that they et their required inspections',Failure of the individual trades to secure
the permits and inspections as equired can DELAY the project,until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner/resident's signa re requesting exemption)
I will call to schedule all required buil•• g inspections necessary for the building permit issued to me.
Date
Address of work location
i
N
c
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
- = }' 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): UP't 5 V rift
Address: Z6 Co L.CC 6( V/( i j E(6411 S
City/State/Zip: Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I,LITa 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.El I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. n Building addition
[No workers' comp. insurance comp.insurance.$
required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs 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' 13.1-1 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 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 t DIA for insurance coverage verification.
- Ido hereby certi nder t e ,'ins and penalties of perjury that the information provided above is true and correct.
Signature: t •�° Date:
Phone#:
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 Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: (( Not Applicable ❑
Name of License Holder: h Css c. //q
a.940 o/9 e (Ac /4/06
License /(�
Addres Expiratio Date
6M Cis' 7)7 -
Signature Telephone
9r'Registered Home Improvement Contractor Not Applicable ❑
Company Nime / Registration umb
I/o/% ray /7 ki as-' fl
Address Expira' n Dat
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G L c.:152,§25C(6)). f.
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 ❑
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, tate and Local Zo '•_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) n Roofing IT
Or Doors IJ
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [E1 Siding[O] Other[
Brief Descriptiog.af-Pro sgfl r ,,�,,
Work: _ �dJ.s'7`G!/ 14,S 4-0( /ee / �/(l/i9/9c
u Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa camplete.the'foilowinq:
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 constructio'. 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 '. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or ellar floor below finished grade
k. Will building conf. 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
7( I, CD(x/// ?C
4 ,ki"e r5" , as Owner of the subject
l property
hereby authorize —TOP //,/-7— L!?/ /ter (7)4t-e
to act o behalf, in I ma rs r .ve to work authorized by this building perrfiit application.
Signature of Owner Date
, 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
ang belief.
Signed under the pans a d penalties of perjury.
_Dk 4
Print Name
Signature of Owner/Agent Date
J
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 Dc. .m ent
r-
Lot Size ..... ; I_ _� _ i
Frontage . ,
Setbacks Front 1 ,
S
Side La R:' � L:!,_._, � j j
i
Rear R _ =•
Building Height I 1
Bldg.Square Footage = ( % n i
I
--- Open Space Footage /o
(Lot area minus bldg&paved ! —1 i , 1 f i
parking)
#of Parking Spaces 3 I I---I r
Fill:
EE f
(volume&Location) I?
A. Has a Special Permit/Variance/Finding ever seen issued for/on the site?
NO Q DON'T KNOW 0 YES 0
IF YES, date issued:;: f
i
IF YES: Was the permit recorded at the Re:istry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book I Pagel and/or Document#1 1
B. Does the site contain a brook, body ►f water or wetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or ne-d to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued: i
C. Do any signs exist on the p-.perty? YES 0 NO (3
IF YES, describe size ype and location: j
D. Are there any prop•sed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, desc .e size, type and location: 1
E. Will the c•'struction activity disturb(clearing, grading,excavation,or filling)over 1 acre or is it part of a common plan
that wil disturb over 1 acre? YES 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
co
• .
55.
. . , , ., . ,. . •DepartmeMt use only
Cif of Northampton Status of Permit -.
,Buii.ing Department Curb-Cut/DrivewayPermit ,, ‘`` -
� f
2' 2 Main Street • Sewer/Septic Availability . '= ' '; :
i I ` ' 203 4 Room 100 Water•/Well Availability
JU� N rth. pton, MA 01060 ! Two Sets of Structural Plans
t 58 1240 Fax 413-587-1272 Plot/Site-Plana ; ', ,
Don'°FF TON MA01060 Other'Specify . '
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -^SITE INFORMATION -
1.1 Property Address: ��
- This section to be completed by office
902. &I/�
Map ' Lot Unit
,Plfra q 1410 tif1,l0oZ y
'>Zone � Overla District
.
, Elm St..District CB District--
SECTION 2=PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
qvt lb S �U (Aici<'�
Na a(Prin Current Ma ilin
Address:
CG ' "/.� -� Telephone
Signature
2.2 Authorized Agent:
0 . .am�t) _ Current Mailing Address:
ah m 4 -✓'
C 4/13-s32- (�,�3O
Signature f 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) OOt Check Number . .
This Section For-Official Use Only _ -_
Date
Building Permit Number Issued
Signature
- -
Building Commissioner/Inspector of Buildings - Date
92 GLENDALE RD BP-2013-1187
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 42-078 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:FIRE DAMAGE BUILDING PERMIT
Permit# BP-2013-1187
Project# JS-2013-001851
Est. Cost: $2000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DALE A SMITH 101196
Lot Size(sq. ft.): 25918.20 Owner: POWERS DAVID S
Zoning: . Applicant: DALE A SMITH
AT: 92 GLENDALE RD
Applicant Address: Phone: Insurance:
26 COLLEGE VIEW HGTS (413) 536-6830
SOUTH HADLEYMA01075 ISSUED ON:6/12/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL INSULATED METAL CHIMNEY
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 6/12/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner