29-229 ors,e A�4�� S/
? r f a�aaci�zisc a 12 II I
LEPf' TMENT Gr EUILD°NG U,SPE=OiYS
iNSP�CTCP 212 Main Sirtct a Municipal Building
lvor bampron, MA 01060
iivr�;E v^�yi��r n LXE TY)?N ACILNOWLEDG-EMENT
The State of Massachusetts allows the homeowner the right under 7SOCMR 108.3.4 to
act as ;.is/her construction sup- :nor. The stare dunes `=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 const uction supe;�Aso; 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/footinas (before backflI).
sonotube holes (before Dour). a rough building insnection(before work is
co-ace-fled) insulation-inspection (if recuir-ed)and_afinal_buildine 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 DEI AY the project until such time as the proper permits and inspections are
made
L 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. y
Date
Address of work
location
• .
the Commonwealth of Alassachuserts
Department of Industrial_-a ccidents
-�-- Once of Invesrig a:ions
600 TVashin�azon Street
. / Boston,ALA 0 111
www.mass.gov/dia
Workers'Compensation Insurance ffida`-it: Builders/Contractors/Eletitricians/PIumbers
_pDIicant Information Please Print Le4ibly
Name(Bu-iness/Orz=ization/Indivirival): 139l e 6; dN6
Address.-_ Zs9i moo, �iy ,� 7
City/State/Zip: �i4� j.� Phone S��C� JAI/6�
ire u an employer?Check the a propreate box: Type of project(required):
am a gene-al contractor and I
1_ I am a employer with � 4. � I 6_ ❑New construction
employees(full and/or part-time)_
�VePd the sub-contractors
12.7 1 am a sole proprietor or partner- listed on the attached sues+ 7. Remodel
ship and have no ezznploy ees These sub-contractors have S. Demolirlon
working for me in any capacity. employees and have worizzers'
[No workers' cow. s,u�ce comp.insurance.* I 9. ❑Building addition I
required_]d. 5. 7 We are a corporation and its 10.0 Electrical repairs or additions
q ]
officers have exercised then
I am a homeowner doing all work 1 I.❑Plumbing repairs or additions
myself. [No workers'camp. right of exemption per MGL 12. Roof repairs
insurance rra n ce required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance requited.]
- nYfF-P11=01 mat=2=0 ooxr,:i until also nil out me sc=on oeiow snowmg - eir woti=s'cotnpmsanon policy miormation.
Homeowners who subttat this affidavit indicating they are doing aE work and men hire outside connectors must subimt a new affidavit mdicatar such.
*Contzwrors that check this box mustanacad an additional shoe:showing the name of the sub-contractors and state whether or not those entities have
e Plovew. If the sib-contactors have=npiove=,they must provide their work='comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and joh site
information. / �;
Insurance Company Name: Z/5 a%�z /l�!G�4)�/ �� S
Policy#or Self-ins.Lic.#. 1cl c. ��/v --�oZ r /-d/ Expiration Date:
Job Site Address: �G,✓I�G ea x&>-DK': 1 City/State/Zip:A/O,9�e 1 G C ' 0
kttach a copy of the workers' compensation policy declaration pace(showing the policy number and expiration date).
Failure to secure coverage as required under Section 2:;A of MGL C. 152 can lead to the imposition of criminal pen allies of a
fine up to$1500.00 and/or one-year imansonment, as well as civil penalties in the form of a STOP WORK ORDER and a fire
of up to$250.00 a day against tiie violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLk for ins-,=c.-coverage verification.
I do hereby certify under the pains and penalties of perjury that the rnfermation provided above is true and correct
Dale-
Phone y14
LOther e Only, too not write rn this area, to he complered by crry or town official
wn: -- ---Ter--mit'License M
thority(circle one):
f Health 2.Building Department 3. City/Town CIerk 4.Electrical Inspector 3.Plumbing Inspector
r son: Phone=-
r
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Constructions Supervisor: / Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
�6 f✓ ✓J�,,n�p T6i Q�(}
Signature Telephone �� 0/0 t1'7— o
J_S6 '41167
9.Registered Home'Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address v Expiration Date
Telephone gZ,r/I67
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 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-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 W' doves Alteration(s) Roofing f7 Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding [O] Other[p]
Brief Description of Proposed ,
Work:.
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing-housing, complete the following:
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 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 TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, �)C ,� 5 L� �2--`l as Owner of the subject
property I
J
her by authorize 1-4 e/ � �440
to ct my behalf in all matters relative work authorized bf this building permit appli ation.
y h G
Signature of Ow0fer Date
l �� %'J ►�'��, asAuthorized
Agent hereby declare that the statements and informati n on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Prinl.Ll,we
Signature of.AwF*w/Agent Date
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
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage % _ _ --
Open Space Footage % •--- ---
(Lot area minus bldg&paved _ ---
Darkin )
#of Parking Spaces
Fill:
(volume&Location) i
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
IF YES: enter Book Page, and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q Date Issued:
C. Do any signs exist on the property? YES Q 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 0 NO Q
IF YES, describe size, type and location:
E. Will the construction activity disturh(mooring, grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO 0
IF YES,then a Northampton StomWater Management Permit from the DPW is required.
! t .;
� Department use only
,Ci#y of Northampton Status of Permit:
g Euilding Department Curb Cut/Driveway Permit
212\ ain Street Sewer/Septic Availability
R m 100 Water/Well Availability
No mpton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot(Ste Plans
Other Specify
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:
Map Lot Unit
Zone Overlay District
�--
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Cu---It M lin Address:, )
Name Print) Q l
Telephone
Signature
2.2 Authorized Agent: )
Name(Sint) Current Mailing dress:
Signature Telephone
SECTION 3-'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building J 6 b 4^ (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
-� Check Number
6__Total° �±-2+3+4+5, _
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
-- --- -- ----- -— ---—
Building Commissioner/InspectorofBw mgs Date
•
BP-2009-0816
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-2009-0816
Project# JS-2009-001213
Est. Cost: $3230.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: B & R SIDING 100465
Lot Size(sq. ft.): 10018.80 Owner: HEBERT DOUGLAS L&MARY J
Zoning:URA(100)//WSP Applicant: B & R SIDING
AT: 176 ACREBROOK DR
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:41712009 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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 4/7/2009 0:00:00 $35.0021528
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo