37-093 (4) tj
-F)
a r
HOME OWNER EXEN.LP ION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CIMR 108.31.4 to
act as his/her construction supervisor. 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 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 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 occunancv
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
Ilze ColnmQnwea! 1 OJ lassachusetts
Department of Industrial_4 cciderts
oy lnvestiga.—ions
600 T ashin-ton St,eet
==
Boston, _V_4 02111
www.mass.gov/dia
Workers' ComDensation Insurance Aflida dt: Builders/Contractors/EIectricians/Plurrbers
Armlicant Infor€nation �` Please Print Le6ibly
?V'=e (Business''Orcani:atiorv'Individuali: U�[�—
Address: 51 9_4&y�0d `t MW C— --
City;/State/Zip: C---A 6hi D [OZ Phone '714-0
Are you an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1.❑ 1 am a employer with 6. f7 New construction
pIoyees (full and/or pare-time).* have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. [—I Demolition
working for me in any capacity. employees and have workers' 9 7 Building addition
[No workers' comp. insurance comp. insurance.:
10.0 Electrical repairs or additions
required.] ❑ We are a corporation and its
:.❑ I am a homeowner doing all work officers have exercised their l 1.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.7 Roof repairs
insurance required_] ' c. 152, §1(4), and we have no
employees. [.No workers' 13.7 Other
comp.insurance required.]
*Any applicant La at citecics box=T must aiso 511 out the section below showing their worke s'compensanon policy information.
' Homeowne:-s who submit this artdavit indica&g they are doins all work and then hire outside contractors must submit a new affidavit indicatin.-such.
}Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and stare 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
inform ation.
Trc_rarct Corrpany Name. —
Policv:ii or Seif-ins. Lic. 7: 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-M- GL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORD ORDER and a fine
o.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 DL,' for insurance coverage verification.
I do hereby certifv under thepains Iandpe/n-alties ofperjury that the information provided above is true and correct
Sizaarur - � ! a(�%�� �8�'�- Date- I � JW►^e, g
Phone
0lfcial use only. Do not write in this area, to be completed by city or town ojjfciaL
Citv or Town: Permit/License r
Issuing Authority (circle one):
i1.Board of Health 2.Building Department 5. City/Town Clerk- 4.Electrical Inspector 5. Plumbing Inspector
6. Other
i
Contact Person: Phone
SECTION 8 -CONSTRUCTION SERVICis
8.1 L ^sed Const-uction Suoe^rsor Not
//��Applicable ❑
Name of License Holder: s�i 7 IO�`T h -Yf>C? (�c0 q '
License Number
:51 Vad 4n a"I T-e,"u Ea4t u;w� c i o L 7 13 •0°I
;ddress Expiration Date
Signature Telephone
I
L Reaistered Home Improver•ierrt Contractor.:° ;, Not Applicable ❑
.w,.w ,. _....
[A:QQL br4wA 4 Cam-+.dd Z C[I mIrbe4( -i W-coL I L-I 5q 5 4
.omoanv Name a Registration Number
S-1 E4k T�nr90 0/0Z-2 311 S 1 PO
.ddress V V Expiration Date
Telephone N 12 .5;24-714D
ECTION 10-WORKERS'COMPENSATION INSURANCE'AFFIDAVIT(M G.L.c. 152,
Porkers Compensation Insurance affidavit must be completed and submitted with this application- Failure to provide this affidavit will result
the denial of the issuance of the building permit.
oned Affidavit Attached Yes....... ❑ No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings ofone(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 10835.1.
Definition of Homeowner:Peron(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 hefshe shall be
responsible for all such work performed under the building permit
As actin.-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 15', (Liability ofEmployers 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 undersized"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
SE--TION 5-DESCRIPTION OF PROPOSED WORK(check all aooiicabie)
i
I New House Addition Replacement Windows Alteration(s) Roofing
I Or Doors Cl
Accessory Bldg. Demolition F New Signs [01 Decks [[] Siding [F—ii Other[Q]
Brief Description of Proposed
Work: T:b ulna' n winds a-'
Alteration of existing bedroom Yes_k,- No Adding new bedroom Yes r✓ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
e n a �aus. comr)fetc t5a f Nwh ? r di o he fai(onri�r :
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 Woedstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of constructien
L Is ccrstn:ction within 1GO ft. of wetlands? Yes No. Is construction within 100 yr. floodpiain 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 T€}BE COMPEETEff=WHEN
OWNER&AGENT ORCONT.RACTORjAPFtIES FOR:$UJILDINlG.PERMIT
S'tz.j'C.A .1� t-10 VA- F �l. „ ,�nr }�Q v„'— as Owner of the subject
proper-,y
hereby authorize �IvO k yzf' h
to act on my behalf, in all matters relative to work authorized by this building permit application.
'O
Sign. re of Owner Date
as Owner/Authcnzed
- ent nerety declare that the sta*.ements nd infernation on the fo going application are true and accurate, to the best cf mymy coo ledge
v
and belief.
Signed under the pairs and penalties of penury.
- -
Pnni Marne
��cr2ture of Owneri�gent °`E
� ~
Sectior 4. ZONING AU Information Must Be Completed. permit Can Be Denied Due To Incomplete Information
Existing PrDposed Required by Zonin�
This column to be E ille1iin by
Building Department
Lot Size
Frontaze
Setbacks Front
Rear
Building Height
Bld.-I Square Footage o
Open Space Fo %
otage
(Lot area minus bidg&paved
DarkinL
of Parking Spaces
(volume&-Location)
A. Has a Special Permit/Yariance/Finding ever been issued for/on the site?
v��~~
NO \v~� YY_� DONTKNO V�r YES �~�~�
�
^
IF YES, date issued
IF YES: Was the permit recorded at the Registry ofDeeds?
NO �
DONTKNOY 0 YES
_
IF YES: enter Book / Page and/or Document#/ �
B. Does the site contain a brook, body of water orwetlands? NO O~~ DON7KNOW 0 YES 0
IF YES, has permit been or need to be obtained from the Conservation Commission? '
Needs tubeobtaned /�� Obtained r-\ Date !
' v�� ' �^/ ' ' L_______-___
�
C. Doahy signs exist on the prope� �� ��/�y� YES \�� N0
I FYES' describe size' type and tocation: �
D. Are there any proposed changes to or additions of signs intended for the property? YES y�\ NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading . orf0�g)over 1ac�or��po�ofacon�n��an
�a1wv||d�udb over 1a�e? YE8K ) NO ���
`~� ~u'
|F YES, then'a Northampton G5�m'VV5e—r Managem6ff Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
ai tment Curb;Cut/Drnreway Perrnrt
treet Sewer/SepticAvailabiiity
{ i
,, 1 "Room' 0 WateiNV elf Auailabitity
Nol i ton, KM. 01060 Two Sets of Structural Plans
pholo4k', 140 Fax 413-587-1272 Plot(Site Plans
F
Other Specify"
APPL14AT10k�-6 06NSTF,WT,{V'"ZEFR B= R, 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
N61 uw`'�-Hov1� G�d(d(J Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
JJJAhra1, 001 &-,JL tk'a,
Na a(Print) Curre Mailing Address:
Telephone
ignature
2.2 Authorized Agent:
T-e*yztcz t�rsft�
Name(Print) Current Mailing A ress:
Dk� Lf 13-
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit apolicant
1. Building Snow (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
6. Total=(1 +2+3+4+5) Check Number
This Section For Official'Use.Oni
:Date
Building Permit Number. Issued:
Signature:
- --------- -- --
Gate
Building Commissionef/Inspector or w ings
File#BP-2008-1116
APPLICANT/CONTACT PERSON ELIZABETH HOOK
ADDRESS/PHONE 51 RIDGEWOOD TERR EASTHAMPTON (413) 529-2189
PROPERTY LOCATION 19 ICE POND DRIVE
MAP 37 PARCEL 093 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: ADD 3 NEW WINDOWS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 079641
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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 Permit DPW Storm Water Management
Demolition Delay
Signature o 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-2008-1116
19 ICE POND DRIVE
COMMONWEALTH OF MASSACHUSETTS
GIs#:
CITY OF NORTHAMPTON
lo
Map:Bck: 37 -093 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Lot: lo
Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2008-1116
Project# JS-2008-001641
Est $Cost: $8000.00
Fee:Cost: PERMISSION IS HEREBY GRANTED TO:
$. Class: Contractor: License:
Cons ELIZABETH HOOK 079641
Use t. Class:
Lot Group:
ft.): Owner: HOWE NICHOLAS R&SUSANNAH
HOOK
Zoning: SR A_ pplicant• ELIZABETH
Phone: Insurance:
Applicant Address: (4131 529-2189
51 RIDGEWOOD TERR
EASTHAMPTONMA01027 ISSUED ON:611712008 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD 3 NEW WINDOWS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET Building Inspector
Inspector of Plumbing Inspector of Wiring D.P.W. u g p
Underground: Service: Meter:
Footings:
g
Rough:
Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame: j/,� 0 Y�{.�1A
Gas:
Fire Department Fireplace/Chimney:
Rough:
Oil: Insulation: A)01-• 2Q j 1
Final:
Smoke >♦' na' JK �.a( •O S'V�
THIS PERMIT MAY BE REVOKED BY THE CI OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL S.
Certificate of Occu anc
Si nature•
Feel e: Date P id: Amount:
Building 6/17/2008 0:00:00 $50.001242
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Coinmissioner-Anthony Patillo