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DEPP_;�TMENT OF BUII.DLNG INSP=01115
INSPECTOR 212 Main.SL=t • Municipal Building
Northamptnn, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CtiIlZ 108. .4 to
act as i.is/her construction sups_ T l:e 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 bacldill).
sonotube holes (before pour). a rough building insaection(before work is
concealed),insulatioii inspection (if required) and-afnal_buildia 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 occupancv
until;the work can be inspected_
If the homeowner hires other trades to perform work(electrical, plumbing&gas) the
homeowner-,;YU 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
ade
I, understand the above.
(H me o er/resident's sign a requesting exemption)
I will call to schedule all required ding inspections necessary for the building permit
issued to me_
Date
Address of work
location
The Commonwealth of 11assachusetts
Department of Industrial Accidents
��1�' Office of Investigations
600 Washington Street
Boston,2VLA 02111
www.mass gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information j! Please Print Legibly
Name(Business/Organizahon/Individual): La,o"ta yall-440 / C�I �T- 4o/(/
Address: - , 6)e M
City/State/Zip: O) t'aiwk'� . /Vh 010? -0193 Phone.,— Z7' — `"! 7
Are you an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1_ I am a employer with 6. -New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- Listed on the attached sheet 7. ❑Remodeling
ship and have no ezrployees These sub-contractors have S. 0 Demolition I
working for me in any capacity. employees and have workers 9. ❑Building addition I
[No workers' cow.h s,i ance coma.insurance.*
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers'co - right of exemption per MGL
� 12.7 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.[✓]Other of 5 5
comp.insurance required]
- ' iy app,can a c er oox r must auo n out a secnon below snowing their workers'compensation.policy mform=on.
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
reformation.
Insurance Compare Name: 41-1- f ,����
y F
Policy or Self-ins.Lic. #: vV Expiration Date: G�
t--foAe-vc� o6�
Job Site Address: a `6 62c�1�E Dr-1 vt'} = e City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ®lam
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$1500.00 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
Investigations of the DLL for insurance coverage verification.
I do hereby e'' nder e p qrYns enaldes of perjury that the information provided bove is true and correct
- ------- - - :�—�j
�gn nire`
Phone T: -
a
LOther only. Do not wrrte rn t}ris area,to be completed by city or town official
n: Permit/License M
hority(circle one):
Health 2.Building Department 3. City/Town Clerl, 4.Electrical Inspector S.Plumbing Inspector
son: Phone T•
SECTION 8-CONSTRUCTION SERVICE
8.1 Licensed Construction Supervisor: 11 Not Applicable JA
Name of License Holder: V1/i `I r r � � C j `"
License Number
-D
Address Expiry itit on l5ate
Signature Telephone
Not Applicable
9'-Reaisteied"ifiorrie Trr►acovefi!ientCoatracfor
6v1-1.1N4d6A4dN Z16 166 97 9
Company Name Registration Number
/P,6, 16r,,, 03
ExpiratioGn Z Date
Address C - `%7 ' r/W 1�(ltv�I2 7 Ae Telephon p y D Q G(I
SECTION 10-WORKERS'COMPENSATION"INSURAN"CE 4FFIDAVIT(M 6.L.c.-1.52;,&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....... 2f No...... 1:1
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 1083.5.1.
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-vear 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 applicable)
New House [❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg_ ❑ Demolition ❑ New Signs [0] Decks [[] Siding[0] Other[0]
grief Descr,i,pption of Proposed
-work: !10 ✓!1, n '12.1 S Tv can c� /1c1 L�
Alteration of existing bedioom Yes No Adding new-bedroom Yes No _"
Attached Narrative Renovating unfinished basement Yes V No
Plans Attached Roll -Sheet
6a !f Nevi douse rici ar adcidr�l�=tom axis€rn4 io�isiltc€, Ea ptete;t w aE(b.WIna:
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 Yes - No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
1. Septic Tank City Sewer Private well City water Supply
SECTION-7a-OWNER AUTHOR]ZATION-TO BE COMPLIETED-WHEIV
OWNERS AGENT OR CONTtZACTORAPPLIES-FOR BUILDIPIG-,PERMIT=
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
7Agent CL�� as Owner/Authorized
hereby eclare that the statem nts and information on the foregoing application are true and accurate,to the best of my knowledge
elief.
Signed under the pains and penalties of perjury.
i7PA
Print Name
07.
Date S Owner/Ag t
Section 4. ZONING7 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
Frontaee
Setbacks Front
Side L: - R L:: R-
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(1-or area minus bldg&pared - -
arsine)
r--
#of Parking Spaces
Fill:
(volume&Location) a
A. Has aSppecial Perm it/Variancne�/e�Finddinng ever been issued f`o+�r/on the site?
/
-- No ( 1 n KiNeW ( 1 VCS L/ 1
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW ® YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained ® Date Issued:
C. Do any signs exist on the property? YES O 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 ® NO
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 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Qepartmerit ctsse:Deity` �= x
City of Northampton Stafus'ofPerm `
Wg
wilding Department Curb 1f3aewayPeu€ -�
s
\ti 212 Main Street SewerfSepho°AaTa>rirl►fi� _
Room 100 Wafer/ Le[lva�#abrC _
..,.,Northampton, MA 01060 �voSefsofStractural=F1`ans� -�
4)h4one\413-587-1240 Fax 413-587-1272 1?IoffS Prans
`' a Qtttec S eci _ -
P
APPLICATION TO CarTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILX DWELLING
'-SECT ON:1�1'1TE INFORMATION
.1 Property Address:
"This sectiarrto 6e'carbpteted 6yoffce
( � b/7J de-
101a Eot fcr
SECTION 2-PROPERTY OWNERSHIPlAUTHORIZEO'AGEAkT
2.1 Owner of Record:
M RI ev tv nyzoy bri" Ryrenc.t A4A
Name(Pri ) Curr nt Mailing Address: (�lQbL
-3 39 S7
Telephone
S gn ure
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION.3-ESTINATEaCONSTRUCTION'COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building :10 ; (a�-Building:.Permit Fee
'yC�C
2. Electrical [.(b}Esfimated Totaf.Cost_of
Construction-from(6)
3. Plumbing Building Permit.Fee
4. Mechanical(NUAC)
5. Fire Protection
6_ Total=(1 +2+3 +4+5) Check Number
This Section For Offii:Fi Jse Only
Building Permit Number._ Issued:
Signature:
Building Commissicner/Inspector of Buildings- Date
File#BP-2008-0356
APPLICANT/CONTACT PERSON LAFOGG&HATHAWAY
ADDRESS/PHONE PO BOX 193 WILLIAMSBURG (413)268-3897
PROPERTY LOCATION 228 ACREBROOK DR
MAP 29 PARCEL 337 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 710 070 70 11"
Typeof Construction: REPLACE FRONT STEPS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 061422
3 sets of Plans/Plot Plan
THE LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION 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 Comrnittee
Permit from Elm Street Commi n
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.
BP-2008-0356
GIs#: COMMONWEALTH OF MASSACHUSETTS
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-2008-0356
Project# JS-2008-000514
Est. Cost: $4000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: LAFOGG & HATHAWAY 061422
Lot Size(sq. ft.): 10018.80 Owner: PURDY MARILYN A
Zoning: URA Applicant: LAFOGG & HATHAWAY
AT: 228 ACREBROOK DR
Applicant Address: Phone: Insurance:
PO BOX 193 (413) 268-3897 WC
WILLIAMSBURGMA01096 ISSUED ON.10/512007 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE FRONT STEPS
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 10/5/2007 0:00:00 $50.0011970
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo