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DEPARTMENT OF BUILDINTG INSPECTIONS
f +
INSPECTOR 212 Main Street • Munic:ipal Building '
Nordi=pton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction sup,:: .- Sor. The state defines "Homeowner" as, "P erson(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_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 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
♦ • H
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) <qy�y-p� y�
Address:
City/State/Zip: Phone.#:
FALe you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 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 employ ees These sub-contractors have g_ ❑Demoliiion
working for me in any capacity. employees and have workers' 9. Building addition
[No workers' comp.insurance comp. insurance.:
❑ g
required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions
3.[r] I 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.]
'Any applicn a checks- ox#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.
*Contractors that check this box must attached an additional sheet showing the name of the subcontractors 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. Lic. #: 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 +ne
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 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.
Signatures Date
Phone#:
L6.0ther ony. Do not write in this area,to be completed by city or town offrciaL
n: Permit/License#
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
S_Reixistereil Home Cmprovement`Eonrtracfor-; Not Applicable ❑
Company Name Registration Number
Address Expiration Date
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 . dome.��ge>�:�aceil>�p�io>r>r
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 E] Replacement Windows Alterations) Roofing
Or Doors O
Accessory Bldg. ❑ Demolition New Signs (0] Decks (M Siding[0] Other[E:]
Brief
Work Description of Proposed 'D F r_k U E t S T Z !'J t EC K� IZt LAC, KC&I— j I ikk(Z-,%
Alteration of existing bedroom Yes No Adding new-bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa !f°N640
640 -ando�r=a ddition,faextstirtci oils
e�c�:cDmaCete-fhe_toltowirg:
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? es - - 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 AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR`APPLIES FOR BUILDING PERMIT
I, 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
I, IL�c�a.-ate Rv�L�s rJ a`Owner/ uthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to th of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Ddte
wr�* _o
Lection 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This colurrm to be filled in by
Buildin.g Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minu.1;bldg&paved
I #of Parking Spaces
(volume&Location)
^ ~
A Has a Special
- r~ � —^ ---
IF YES, date bsue :, /
IF YES: Was the permit recorded ut the Registry uyDeeds?
NO �� D
k_/ um/ xmuxv YES
IF YES: enter Book � / raga| ��-- and/or Document#'
B. Does the site contain a brook, body of water orwetlands? NO 0 DON'T YES
IF YES, has a permit been ur need to be obtained from the Conservation Commission?
Needs tobeobtained x�� 0�ta(oe� v~� Date
�
^~� v_� '
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location: �
D. Are there�D,p����sedchangestoor additions of��gnsintendedfortheproper�'? YES �~� NO
' �~/
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradiexcavation,o,filling)over 1 acre o,is it part ofa common plan
that will disturb over 1acre? YES NO
0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
De dent use o _
t?a �
City of Northampton Status o£Penn _
t i
w
Building Department ErrrtCrirraewrlx�e ��
212 Main Street sewer6SeptrcAvaTabrl � x
Room 100 ester ekAvatfabtfa
x �
1qorthampton, MA 01060 >�nrc Sets of`Stni3twi f`Plans
phone X113-5-7-1240 Fax 413-587-1272 f?tof�Srte Paf hs �
77 777777-F
� athecSpeclfyr _� ' _~
S `
"'APPLICAADQN' ��RUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
sTE IN FORMATION This sectiottta fJe cornpiefed byoffice
rooerty Address: ;
�bt Uc�it
'�' L�-5�,�� , ti—Qt� C� l,Ufc�`l. Zone Overlay,Drstnct
ThErri St Distrrct- 'CB Distiicf
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name Print Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
comoleted by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical `(b}Estimated Total Cost-of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HUAC) 17 !f�
5. Fire Protection
6. Total =0 +2+3+4+5) -Check Number
This Section For Offic altise Only
- - Date
Building Permit Number.. issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2008-0173
APPLICANT/CONTACT PERSON RAMSDEN RICHARD A&DIANA D
ADDRESS/PHONE 375 BROOKSIDE CIR FLORENCE
PROPERTY LOCATION 375 BROOKSIDE CIR
MAP 29 PARCEL 282 001 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
T_ypeof Construction: DEMO EXISTING DECK REPLACE REAR STAIRS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License
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
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-2008-0173
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)
Catep_ory: BUILDING PERMIT
Permit# BP-2008-0173
Project# JS-2008-000256
Est. Cost:
Fee: $30.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group Homeowner as Contractor
Lot Size(sq. ft.): 18033.84 Owner: RAMSDEN RICHARD A&DIANA D
Zoning: URA Applicant: RAMSDEN RICHARD A & DIANA D
AT. 375 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
375 BROOKSIDE CIR (413) 585-5970 O
FLORENCEMA01062 ISSUED ON 812012007 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMO EXISTING DECK, REPLACE REAR
STAIRS
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 8/20/2007 0:00:00 $30.004740
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo