29-232 (2) O4•(1�A1P��
Lxtly of Nort4ailiptan z
$� � �lassacJ�useffs -
r � w
5' DEPARTMENT OF BUILDD\YG INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as i:is/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 backm
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 occupancv
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
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): lL O�e
Address: zD OYP-e-,'yY Z22e �oe9�
City/State/ZIPS !'�R/�Wi Nl�- U107,� Phone#:
7Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a 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.( I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no emiployees These sub-contractors have g. F-1 Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp. insurance.
$ 9. ❑Building addition
required.] 5. ❑ We are a corporation and its 10.F-1 Electrical repairs or additions
3.❑ 1 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.[ Other
comp. insurance required.]
--*tXny app—Titan a c ec ox must also till out the secnon below s owing 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: C
Policy#or Self-ins. Lic. #:' Z 4- Vb,, `Expiration Date: C� -Z'�Q z
Job Site Address: 1 Sn/Ut A// &-Q Fb1t,-)Le_ MA ity/State/Zip: Fko^er,� ZIZS 0/�6�
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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Sitnature:
/ / Date: 727V-62
_
Phone#: `7 / 3 S 7-12�,(
Official use only. Do not write in this area, to be completed by city or town offlcial.
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
/ Not Applicable ❑
Name of License Holder:f_k , m`.
° License Number
d Q ,�o � So�1-1 ► rt 7 S7 009'
Address Expiration Date
Signature Telephone
9 Registered Non e_I"mproyeinent'Contractor _ ,� , .' ;` Not Applicable ❑
Company Name Registration Number
Q �.?d 070
Address , Expiration Date
r l - 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...... ❑
11..=Home owner Exe>lnp�t6h
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-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.
i Homeowner Signaturer���
r
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors r7l
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[0] Otherj
Brief Descripti n of Propose
Work: 'CrC9nn 12000 V
Alteration of existing bedroom Yes No - Adding new-bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
se:If New house and or-acldtEOn=tom exFs€ a Eiousina'cOinialee the fio[PovrElng:
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 o. s 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.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a OWNER.ACITHORIZATION.-�T�1 BE''COMPLETED WHEN
OWNERS AGE1�T°{kC'!o'w'--EiAOTo' A0P t IE 6F,'JjiA W PERMIT
I [° O, K�VA L1 -V z-2 7, as Owner of the subject
property –�– -R,
�,/
hereby authorize /qI C IIA45z � ,'l0 415AI"p
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner F Date
( as Owner/ �nowledge 4anelief.herebthe best of my
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Age Date
" w
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 Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A Has a Special Pe it/Variance/Fi ndi been issued for/on the site?
DON'T =."~ ^������ �� YES �--__---
IF YES, date issued:
IF YES: Was the permit recorded at the Registry ufDeeds?
��
NO �� DON'T VV KNO YES
IF YES: enter Book Pugei � and/or Document#' �
B. Does the site contain abrook, body of water orwetlands? NO 0 DON7KNOV 0 YES 0
IF YES, has o permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained ^��v~� Obtained �-«_�� Date'
C. Do any signs exist nn the property �� ��� Y[3 v�� NO �_/
| '
IF YES, describe size, type and |ucudun: .
D. Are there any proposed changes tour additions of signs intended for the property? YES NO 0
IF YES, describe size, type and location: / |
E Will the construction activity disturb grading.excavation,m filling)over 1acre or is it part ofacommon plan
thaw0dksturbovar1oom? YESK ) NO K��)
��
IF YES,than o Northampton Storm Water Management Permit from the DPW io required.
Depaftm& t use only
City of Northampton Status of Permrt
Building Department urb�.Qu pyew y -ennrt
v
212 Main Street Sewer6SeptrcAvarlabrlity. k
Room 100ater/Ut�el[Avartabrtif}r
��O Northampton, MA 01060 �o-SetsofStrucfcrr4-'p
Z�phone 413j587- 240 Fax 413-587-1272 Plot/SrtePlans -
;� � Qther Specify
ApPL16AT10N TO CONSTACT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
7777]SECT,IOK --NFORMATION `
This`section to be completed by office
1.1 Property Address:
(`JLe ♦� �`/Q Map Cot Unit
Z;one Overlay
District-
Elm St-District CB District '
SECTION 2-PROPERTY'OWNERSHIP/AUTHORIZED AGENT -
2.1 Owner of Record:
DA V.1_V E 9P A4A 4!-rHI! r.z4lE T:7— l S S Prone_ Ht IMC
Name(Print) CurreyyWaili Address:
Telephone
Signature
2.2 Authorized Agent:
a 0y 1110M ,SOv'
Name(Print) Current Mailing Address:
q/ '
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building {a)Building Permit Fee
Chan, 12e �r�
0
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Section For Offical'Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
.•
BP-2008-0209
Gam#: 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-2008-0209
Project# JS-2008-000327
Est.Cost: $1040,00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MICHAEL MCKENNA 132070
Lot Size(sq. ft.): 16030.08 Owner: HENTZ DAVID E&MARTHA G
Zoning:URA Applicant: MICHAEL MCKENNA
AT: 118 SPRUCE HILL AVE
Applicant Address: Phone: Insurance:
209 POMEROY MEADOW RD (413) 527-1266
SOUTHAMPTONMA01073 ISSUED ON.812912007 0:00:00
TO PERFORM THE FOLLOWING WORK.-REBUILD CHIMNEY FROM ROOFLINE
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 8/29/2007 0:00:00 $25.002819
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo