31A-150 City of Northampton
{ Massachusetts ? -° 1
' DEPARTMENT OF BUILDING INSPECTIONS
m
212 Main Street • Municipal Building ,
r Y Northampton, MA 01060rE Z1~4
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 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
r
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 4 Please Print Le ibl
Name (Business/Organization/Individual):
Address: 5� �/%� S � Y- —
City/State/Zip• V/C(} �C 10 4 Phone #: / ` '7�
Are you an emplo Check the appropriate box: Type of project(required):
L❑ I am a ployer with 4. ❑ I am a general contractor and I
em oyees(full and/or part-time).* have hired the sub-contractors 5 ❑ New construction
2. am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g• ❑ Demolition
working for me in any capacity. employees and have workers'
9. Building addition
[No workers' comp.insurance comp. insurance.
� ❑
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 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. Other A!�� ,4�C-
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.
lContractors 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. Lie.#: 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 o nsurance coverage verificatio .
I do hereby pertify un r e pains a7dlii s p j ry that the information provided above is true and correct.
Si la e: Date: I Vlezl 2
Phone#: / /A"D -1 k--) 7
- - -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 7 Building Department 3. City/Town Clerk 4.Electrical insnector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ndsor: f� Not Applicable 0
Name of License Holder: / /!(mil / 'x 4�^ � 6 Z 7 7
License Number
(> 7 -! !Q h � -1c�" /Cyr
ess Expiration 6ate
p ture Telephone
9Re isteretl Home,l o�ement Co f'� ctor _ ;3 ,r <<yr,, ;; Not Applicable ❑
_om an Name Registration Num r
Address _ Expiratio Date
'6 24 2�ZJ Telephone S
SECTION 10- KE
WORRS COMPENSATION INSURANCE AFFIDAVIT ,G L c:152,§25C(6))
Workers Compensation Insurance affidavit nWst be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildin ermit.
Signed Affidavit Attached Yes....... No...... ❑
s mr n
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
SECTION 5-DESCRIPTION OF PROPOSED WORK.(check all"a'pp[ica6le)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [lam] Decks [M Siding[0] Other[
Brief De iption oLProposed //
Work: I' —4-
Alteration of existing bedroom Yes No Adding new bedroom Yes No /
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
sa._lfttewfiouse,and,or=addition t x�stin housin ,com lefe the`follown
a. Use of building:One Family Two Family Other
5. 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?_&At ZA Fireplace or Woodstoves Number of each
g. Energy Conservation Compliance. asscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. I onstruction 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-T0 BE COMPLETED WHEN '~
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized
Agent ereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
S' ed der the pains pd penalti of perjury.
/#!I-nrh Name
Siuna wn�r//Ag`n�t Date
^
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by7oning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage OX
Open Space Footage %
(Lot area minus bIdg&paved
#of Parking Spaces
(volume&Location)
A. tiasa�-peciw been issued for/onthe site?
NO \_� DONTKNOYV ��� YES v_���
IF YES, date issued:!
IF YES: Was the permit recorded h�� Re /try ofDeeds�
y_�
NO DON'T YY KNO YES
IF YES: enter Book P /or Document#!;
VIDON7 /~~\ /~~\B. Doesthes�ecuntanabrook bodyofwaterorwet�nds7 N0 KNOVV \~~� YES \~�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs 1obeobtained /-� Qbtained /-~� Issued:
�~� ~~^ '
�
C. Do any signs e�ston the proper� —�� YES v_� NO
,
|F YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb( hng.gnsdin g _
on.or0|ing)ovor1ooreorioitportofaoommonp|on
that will disturb over 1acre? YES _ NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
,
Ci_t of Northampton Status at Permit
c�
RECEIV�lding epartment Cu bv,°utlDrl rewa ,Pemltt � � '
M in Street Sewer;Septicyaildbtlit�
vi
OCT Ro m 100 1tllate e11�Avarlab�tjr: v �
h mp on, MA 01060 TwoStssafStructura as� . . �.. � ,�
Deer.of 413-58 -1 0 Fax 413-587-1272 P� I e (ans t }
UILDMG IN
SPECTIO
NORTHAMPTON MA 07060 NS Qfher 5 ecl
p ,
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 =SITE INFORMATION
This section to be completed by Office
1.1 Property Address: '
llMap Lot "� Unit ''
Zane Overlay*District
��
a,4
=Elrn SY"I7istnct '• CB Distract "
SECTION.:2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: !
I A-
_56-641T I j- M&I AA4 ;k
lqc
Name(Print) Current Ili A dr s:
ff
Telephone
Signature
2.2 A orized A en� T ,
,t I e(Print) Current Mailing Address:
i ure Telephone
SECTION 3=ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only"
completed b permit applicant
1. Building G (a}'Building Permit Fee
w
2. Electrical (b),E§timated Total"Cost of `
Construction from
3. Plumbing Building'Permi#Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Onl
Building Permit Number:"- Date
Issued:
Signature:
Building Comm issionerllnspectoi of Buildings,",' Date
File#BP-2013-0423
APPLICANT/CONTACT PERSON PATRICK J MARTIN
ADDRESS/PHONE 103 SHERIDAN ST CHICOPEE (413)250-4641
PROPERTY LOCATION 25 MAYNARD RD
MAP 31A PARCEL 150 001 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 t—X G2- 4 r
Fee Paid
T_ypeof Construction: REPAIR CHIMNEY FROM ROOFLINE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 77732
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
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.