29-185 (3) OWPR-05-04 10 : 15 AM BPS- 00- 4137823200 P. 01
v
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HOMEOWNER AND CONTRACTOR AGREEMENT
Required Notice:All residential contractors and subeOntractors are required to be registered with the
Massachusetts Board of Building Regulations no standards, unless spec malty exempt from
rag,'strah'an. Inquirles conc+eming registration should be directed to: Director, Home Improvement
Con&acforRez?i:trstton. One Ashburton Place, Room 1301,Boston,A4a 02f 06(617) 727-8698.
Required Notice:NOTICE!OF CANCELLATION
The Owner may cancel this Contract if It Is signed at a place other then the
Contractor's business address,if the Owner notil{es the Contractor In writing of his or her
Intention to do to not later than midnight of the third business day following the signing of the
on
i {
YOU MAY CANCEL THIS AGREEMENT, 11F'IT HAS BEEN SIGNED BY A PARTY
THERETO AT A PLACE OTHER THAN AN ADDRESS OF THE SELL€r"s, W"rSl^vii {
MAY BE HIS MAIN OFFICE OR OR NCH TH RFOF, PROVIDED YOU NOTIFY TIME 1
SELLER IN WRITING AT HIS MAIN OFFIC OR BRANCH BY ORDINARY MAIL
POSTED, BY TELEGRAM SENT OR BY DELIVERY, NOT LATER THAN MIDNIGHT {
OF THE THIRD BUSINESS DAY FOLLOWING THE SIGNING OF THIS AGREEMENT.
SEE THE�ATfiAC,YEB NOTICE OF CANCEL4ATION FORMS LE OF
{ THIS RIG 1.
Con Signature -mar's Signature
This Agreement is made this day of i 2003,by and between
Michaei Moore. DBA: Building Renovation Se ices, having a principal place of business
located at 1321 Sred16 _Road. Springfield.Ma Qati 18 hereinafter referred to as"Contractoe',
and KJJbdn Catiett, Owner of subject property ideated at 118 Dsorfield Dr1ve.Eiorence. Ma
1 ',hsraInafter refereed to as"Owner".
WHEREAS the Contractor intends to repair th* property located at, UQ Deerfield flrive.
Florence.MA D1 2
NOW THEREFORE, the Contractor and Owner; for the considerations hereinafter named
agree as follows;
i
Tifp of Wartt amptan
I�ASSAC}'liSttt6 - Iii
d, DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060
>r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction sup(-, sor. 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 rouzh 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
t.
-t ttnx rT
? 6 f3�L57 HCII 316CII7 ("_)
Ii
m DLPARTMENT OF SUILDD? G INSPECTIONS
212 Alain Street ' Municipal Building
2,rorthampton, Mass. 01060
NVORICER'S COATPENSATION INSURANCE: AYFI DAVI-T
(llccr.:cJrc=mitts^}
,,with a principal place of bushmsslresidence an
(svceUciq i w!p)
do hereby cenj, w0cr the Qns and 13 eis2ltic: of k i I tIlai:
Iarse an employer providing the folloWng ;orr:c"5 colnpu uon covemle or no
employees worping on t?ris job:
why
0100mman Corspam) ( c c;Nu-,bcr) (r>'imAn Datc)
f j I a-r,-i a sole propnetor, gtritrai conrc--or non cowoer (a cle one) and 't;a{-e iurtd
th-c contractors Red beim Wo Compns�a 0r1 CIiC'.cS:
(Name of Contactor) NuinlYr) Datc)
010mc of Contactor) _ (1nsJr=rcc do s an yip Nt tnirr; (1 ir:tio).Date)
(Name of Contractor) (Ins�rane� Co may; }i'olic, Nt{.,is1:R�r) (.=.x;.::,a c, Date)
- (Name of Contractor) —- (Tors ranee ComT�Lny�f oucJ Nfll h✓--r) - �,F.:i;:' !i10:: Da(e)
(.^.!I.IGl-`.dr11�CY'.?�S:::GS'.:t:!._r;•�•-��-1 �_:'.�.:::...'_ _:::_:" _
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UPI scalar of en.=V wyor ucnicr Lc Wo kcfL ai`;x.ritiOn?.ci
I uadcrzta d tbit a copy of thsL state... rn y tin IY{iartzrni o£Ir>hturiJ A,,&i &Oiri w of for Q-
eovmge va-licztioc and that Gil ue to:plc co -T, ut sc�,ie�25A oC?.(CI.152 can Ic d to the im ziticvz oCc 1 PL-
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cocssuti g of a fin'of up to S 1-SQU.00 any 'Cc to cr.:}- r.:.1 evil xru2tia in tic;cnn cf n S:c•,t`;y'crc Ovd'tnj
oC &y t a.it;;t ar- .
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SECT3AN 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder Avic—��- �J� -- C 1�:,
License Number
Address Expiration Date
2
Signature Telephone
�
Regis e e `'orne "mar'ovement"'Contractor ,� r Not Applicable 0
Company Name Registration Number
^
(/1 3 /CD C4
Address Fxpiratia to
Telephone_2,t '
$ECTIONWOKERS'COMPENSATION NURANCEAFFIDAVIT(MG: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...... ❑
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
c •1�
SECTION DIES R PTtOI OPOSEDVORK' check all' Ocat le
New House ❑ Addition ❑ Replacement,Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition New Signs [ Decks [ Siding[ ] Other [ )
Brief Description of Proposed W rk: l -3C
Alteration of existing bedroom Yes `v' No Adding new bedroom Yes —1 Z No
Attached Narrative 0 Renovating unfinished basement Yes _; No
Plans Attached Roll 0 - Sheet 0
m..�, .
eewe ou a "nd o adiiition to.ezistmg hou'si'ng�comp`i"e�e fhe'foilowin
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: 3 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? � �j. Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck 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 _S
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer- Private well City water Supply
SECTIOPl7 WOWNER AUTHORIZATION -TO BE COMPLETED( WHEN
OWNEkSAGENORCONTRACTOR LIES TOW
BUILDING PERMIT
as Owner of the subject property
hereby authorize to ac on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
C-0 NJF-f 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 and belief.
Signed under the pains and penalties of perjury.
VA� c =am
Print Name i L
Signature of Owner/Age Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO tZ— DON'T KNOW YES
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
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:
t
Y
x
11�
,:City of Northampton o .
wilding Department
212 Main Street
Room 100
North mpton, MA 01060x
hone 413-5 7-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION i-SITE INFORMATION
1.1 Property Address:
This sect�o�x to be completer)bg office
t tJnit
Zone Overlay D�stncE
Eltn St.D�stnct ,G8 District
SECTION.2-PROPERTY'OWNERSHIP/,AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature ;eS L-i L—i 2--
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED GONSTRUCTION'COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by..permit applicant
1. Building '� (a)Building Permit Fee
2. Electrical �/ (b)fstimated_Total Cost of
t/ Construction from 6
3. Plumbing Building;Permit Fee
4. Mechanical (HVAC) �p
5. Fire Protection �-P
6. Total = (1 +2 + 3 +4+ 5) ( / 4 ` =- Check Number
This Section ForOfficiaLUse Onl
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
" - a
118 DEERFIELD DR BP-2004-0962
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map_Block: 29- 185 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-2004-0962
Project# ]S-2004-1422
Est.Cost: $11400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MICHAEL MOORE 135584
Lot Size(sa.ft.): 14984.64 Owner: CATLETT KATHRIN M
Zoning:URA Applicant: MICHAEL MOORE
AT. 118 DEERFIELD DR
Applicant Address: Phone: Insurance:
P 0 BOX 5942 (413) 782-3200 Workers
Compensation
SPRINGFIELDMA01118 ISSUED ON.415104 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF, INSTALL REPLACEMENT
WINDOWS & DOOR
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• Receipt No: Date Paid: Check No: Amount:
Building 4/5/04 0:00:00 6703 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo