29 -325 333 Acrebrook BP-2019-0561333 ACREBROOK DR
GIS#:
Map:Block: 29 -325
BP-2019-0561
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot -00 l PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
~Pe~rm=it~: ___ B_ui_ld_in_g DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: New Single Family House BUILDING PERMIT
Permit# BP-2019-0561
Project# JS-2019-000914
Est. Cost $110000.00
Fee: $1210.00
Const. Class:
Use Group:
Lot Size(sg. ft.): 25700.40
Zoning:
PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
YEUGENEY SOLOKHIN 108714 --~~-
Owner: DZHENZHERUKHA VITALY
Applicant: YEUGENEY SOLOKHIN
AT: 333 ACREBROOK DR
Applicant Address: Phone: Insurance:
170 TIMBERIDGE DR (413) 485-8556 WC
RUSSELLMA01071 ISSUED ON:11/712018 0:00:00
TO PERFORM THE FOLLOWING WORK: DEMO EXISTING BUILDING ONLY: FULL
PERMIT PENDING PLAN REVIEW
POST TIDS 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 11/7/2018 0:00:00 $1210.00
212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272
Louis Hasbrouck -Building Commissioner
File# BP-2019-0561
APPLICANT/CONTACT PERSON YEUGENEY SOLOKHIN
ADDRESS/PHONE 170 TIMBERIDGE DR RUSSELL (413) 485-8556
PROPERTY LOCATION 333 ACREBROOK DR
MAP 29 PARCEL 325 001 ZONE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
T eof Construction:
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 108714
3 sets of Plans / Plot Plan
T
REQUIRED DA TE
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFf)RMA TION PRESENTED:
_(./_ PApproved __ Additional permits required (see below) /)ru,..J) ~ t..tt
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
___ Demolition Delay
Signature of Building Official
____ Permit DPW Storm Water Management
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 ofMGL 40A. Contact Office of
Planning & Development for more information.
Department use only
City of Northa pto~-=-=--=~~;...-;;;;..
Building Depa me t
212 Main St eet
Room 10
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
_3>33 If er<:_hrDD k Do Map
This section to be complete? office )q Lot 2~ Unit. __ _
Zone------Overlay District. _____ _ f{4H,a_,.,, rf"<M /11 //-
_______________________ E......,rm St. District. ______ CB District. ____ _
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
Telephone
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Official Use Only
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5)
(a) Building Permit Fee
(b) Estimated Total Cost of
Construction from 6
Building Permit Fee
Check Number
This Section For Official Use Onl
Date Building Permit Number: ___________ _ Issued: _________________ _
Signature: ------------------
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
~t-_ ~/--;) S7 '1 -J3 7<t
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing p reposed Required by Zoning
This column to be filled in by
Building Department
Lot Size IC 11
Frontage ! I I
Setbacks Front CJ [ c=J
Side L:r==:J R:c=J L:[ ---R·i! CJ --~
Rear CJ [ CJ
Building Height CJ C ......., CJ --'
Bldg. Square Footage r---' c=J % C L__..
,-----,
c=J ....___J
Open Space Footage .-----, CJ % ·C (Lot area minus bldg & paved L.____J . CJ
oarkine:)
# of Parking Spaces CJ CJ
Fill: I (volume & Location)
--,
I
A. Has a Special Permit/Variance/Finding ever teen issued for/on the site?
NO O DON'T KNOW O YES 0
IF YES, date issued:;
'--------'
IF YES: Was the permit recorded at the Registry of C1eeds?
NO O DONT KNOW O YES 0
IF YES: enter Book Pogei and/ or Document #
B. Does the site contain a brook, body of water or wetl,inds? NO Q DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtair ed 1 rom the Conservation Commission?
Needs to be obtained 0 Obtained
C. Do any signs exist on the property? YES
IF YES, describe size, type and location:
0
0 , Date Issued:
NO 0
D. Are there any proposed changes to or additions cf sir:ns intended for the property? YES Q NO 0
r----------------------,
IF YES, describe size, type and location: L--------------------~
E. Will the construction activity disturb (clearing, grading, ~xcavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO ()
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 8 • CONSTRUCTION SERVICES
8.1 Licensed Construction ' Not Applicable D
Name of License Holder :._.f'--='...J..::..1-'--"-'-'----=----=-..:;.,.,:..,i...;;;;...;.....Jc...:}_V\'--'--------
License Number
Expiration Date
Not Applicable D
l°t3 q :;2.5=
Registration Number
1i-01-Jb;).u
Address Expiration Date
OIDJo
SECTION 10· WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) I
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 ....... D No ...... D
SECTION 5-DESCRIPTION OF PROPOSED WORK (check all applic abl~ :)
New House 0
Accessory Bldg. 0
Addition D
D
Replacement !Nin
Or Doors []
dows Alteration(s)
Demolition New Signs [C:1]
Brief Description of Proposed Work: ______________________ _
Alteration of existing bedroom ___ Yes ___ No
Attached Narrative
Plans Attached Roll -Sheet
Adding new bE
Renovating u 1fini:
6a. If New house and or addition to existing housing, c >m1
a. Use of building : One Fam ily ___ _ Two Family ____ Oth1
b. Number of rooms in each family unit: ______ Number of Batt
C. Is there a garage attached?
d. Proposed Square footage of new construction.
e. Number of stories?
f. Method of heating? --------------Firep ace
Decks [0
,droom Yes
,hed basement
>lete the following:
lr
1rooms
Dimensions
; or Woodstoves
D I Roofing D
Siding [D] Other [DJ
No
Yes No
Number of each ---
g. Energy Conservation Compliance. ---------Massche ck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No Is 1
j. Depth of basement or cellar floor below finished grade ___ _
k. Will building conform to the Building and Zoning regulations?
I. Septic Tank__ City Sewer __ _ Private well Ci
SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PEF.MIT
I,------------------------property
hereby authorize ------------------
to act on my behalf, in all matters relative to work authorized by this bu ldin~
Signature of Owner D
:onstruction within 100 yr. floodplain ___ Yes __ No
Yes No. -
ty water Supply
, as Owner of the subject
1 permit application.
3te
I, , as Owner/Authorized
Agent hereby declare that the statements and information on the foregning application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
SECTION 8 -CONSTRUCTION SERVICES
Not Applicable D
CS -I ti~ "f /LJ
License Number
Expiration Date
Not Applicable D
Company Name Registration Number
Address Expiration Date
_____________________ Telephone ______ _
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c.152, § 25C(6)) I
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 ....... D No ...... D
...
SECTION 5-DESCRIPTION OF PROPOSED WORK (check all appli< ablt J
New House D
Accessory Bldg. D
Addition D
D
Replacement Win
Or Doors []
dows Alteration(s)
Demolition New Signs [CJ] Decks (0
)J £il.Q...W O\'L.l
Alteration of existing bedroom ___ Yes ___ No
Attached Narrative
Plans Attached Roll -Sheet
Adding new bE
Renovating u fini
·:droom Yes
,hed basement
&a. If New house and or addition to existing housing, c Jmf >lete the following:
a. Use of building : One Family ___ _ Two Family ____ Oth er
b. Number of rooms in each family unit ______ Number of Batt 1rooms
c. Is there a garage attached? ___ _
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? --------------Fireplace s or Woodstoves
D I Roofing D
Siding [DJ Other[D]
""~1 l ;)-t1J Ff a.d~
No
Yes No
Number of each ---
g. Energy Conservation Compliance. ---------Mas3che ck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No Is
j. Depth of basement or cellar floor below finished grade ___ _
k. Will building conform to the Building and Zoning regulations?
I. Septic Tank__ City Sewer __ _ Private well C
SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WI IEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PEHMll
Signature of Owner D
:onstruction within 100 yr. floodplain ___ Yes __ No
Yes No. -
ty water Supply
.
, as Owner of the subject
..
J permit application.
/IJ-().5-)8
ate
I, , as Owner/Authorized
Agent ere y declare that tfie statements and information on the foreg Jing application are true and accurate, to the best of my knowledge
and belief.
,
'•.
-.it•·
·,'j ~
• r ",l.
I I
VADIM SOLOK
'i,
VADIM SOLOKHI~
32 MARLENE DR. ~
FEEDING HILLS, MA 01030 Undersecretary
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Const_r-1,1.ttM~'--ls~~rvisor
.... ~ r I
,1 . E"~ires: 08/19/2020 CS-108809 -/ /
VADIM SOLOKHIN .• --
32 MARLENE~ . .:;:
FEEDING HILLS-¥A 010-30 , \. ~
~()f'i'S;:\0"t\~
Commissioner
Cityof
·xorthampton
Demolish 333 Acrebrook and HERS Raters
1 message
Louis Hasbrouck <lhasbrouck@northamptonma.gov>
To: arkbuildtech@yahoo.com
Yeugeney,
Louis Hasbrouck <lhasbrouck@northamptonma.gov>
Wed, Nov 7, 2018 at 1 :24 PM
You can demolish the house at 333 Acrebrook Drive. I'll review the building permit and let you know what I find.
You do need a HERS rating on the house. Here are a few names.
Adin Maynard
His and HERS Energy Efficiency
12 Perkins Ave
Northampton, MA 01060
413.658.8784
info@hhefficiency.com
Jamie Callan
Matt Turcotte
Powerhouse Consulting
4 79 West Street
Amherst, MA 01002
(413) 230-3043
jamie@powerhouseenergyconsulting.com
Center For Eco Technology
320 Riverside Drive
Florence, MA 01062
413-586-7350
info@cetonline.org
Louis Hasbrouck
Building Commissioner
City of Northampton
Town of Williamsburg
(413) 587-1240 office
(413) 587-1272 fax
Building Permit Fees 333 Acrebrook Drive New House
Square Ft
1008 1st
1008 2nd
2016
Cost/ psf
$0.50
$0.50
$0.50
1008 basement $0.20 ~
216 porch ~
144 deck /$0.20
1368 $0.20
Permit Fee
$1,008.00
$273.60
II ~ JD
$1,rO /1
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street• Municipal Building
Northampton, MA 01060
Fee Calculator for Residential Properties
Location:
Basement @ .20
1sr Floor@ .50
2nd Floor@ .50
% Floors, Finish Attic, Garage @ .20
Deck / Porches @ .20
Square Footage
Total:
Amount
}'I?
) ) JS-:J---
J
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building
Northampton, MA 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
(Please print house number and street name)
Is to be disposed of at:
' J V'C:..
Or will be disposed of in a dumpster onsite rented or leased from:
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of l°'rlassachusetts
Department of lndusftial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass. govldia
\Vo1·kers' Compensation Insurance Affidavit: I uil lers/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PE~ ITING AUTHORITY.
A Iicant Information
1.0 lam a employer with ____ employees (full and/or part-time).*
am a sole proprietor or partnership and have no employees working for ne in
any capacity. [No workers' comp. insurance required.] 3.o lam a homeowner doing all work myself. [No workers' comp. insurance r quin d.] t 4.o lam a homeowner and will be hiring contractors to conduct all work on m r property. l will
ensure that all contractors either have workers' compensation insurance or ire S< ,le
proprietors with no employees.
5.Q lam a general contractor and l have hired the sub-contractors listed on the .:ittacl,ed sheet.
These sub-contractors have employees and have workers' comp. insurance ! 6.o We are a corporation and its officers have exercised their right of exemptic n per MGL c.
152, § 1(4), and we have no employees. [No workers' comp. insurance req, ired.
Please Print Legibly
Type of project (required):
7. ~New construction
8. D Remodeling
9. ~emolition
10 J8] Building addition
l l .J2f Electrical repairs or additions
!~Plumbing repairs or additions
13.0Roofrepairs
14. 00ther _______ _
• Any applicant that checks box # l must also fill out the section below showing th, ir w rkers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and th, n hin: outside contractors must submit a new affidavit indicating such.
!Contractors that check this box must attached an add.itional sheet showing the oar te of :he sub-contractors and state whether or not those entities have
employees. lfthe sub-contractors have employees, they must provide their worke·'S' comp. policy number. =====================
I am an employer that is providing workers' compensation insu, anc,i for my employees. Below is the policy and job site
information.
Insurance Company Name: 5a,Qlf TAIS ~ <)'---_------
Po1,,y # ocSelf-ins. Ld AWC;--7"0c) -=03J~/ ,(_~--Expiration Date: {);;).-0 c5' --;;)..OJ 9
Job Site Address: 33 _3 ~'Cr..bCl'X) ~ d-___ City/State/Zip: If! orfA.g l,tj p/o Y1 /1111-
Attach a copy of the workers' compensation policy declaratio pa1~e (showing the policy ntimher and expidti<iudate).
Failure to secure coverage as required under MGL c. 152, §25A i, a c irninal violation punishable by a fine up to $1,500.00
and/or one-year imprisonment, as well as civil penalties in the form ol" a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of t may be forward~d tc the Office of Investigations of the DIA for insurance
coverage verification.
Si nature:
Official use only. Do not write in this area, to be completed hv ci~v or town official.
City or Town: ________________ Pe mit/License # ______________ _
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Cieri: 4. Electrical Inspector 5. Plumbing Inspector
6. Other-------------
Contact Person: ________________ _ Phone#: -----------------
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as " ... every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states ''Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies {LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in ___ (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
Revised 02-23-15
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA02114-2017
Tel.# 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Information an•l instructions
Massachusetts General Laws chapter 152 requires all employe s to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as " ... every per,on in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including th i leg al representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or ther legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartme ts and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not bee mse of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or loc.il lkensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to c1 nstrnct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of co11 plh1nce with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states ''Neither the c )m.rLOnwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work unt l acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contra,;ting authority."
Applicants
Please fill out the workers' compensation affidavit complete!), by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address a11d phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partn.!rships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation ir surance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to he Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affid: vit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not: the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to )bta n a workers' compensation policy, please call the
Department at the number listed below. Self-insured compani.!s sl.ould enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibl: . The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Inv estig:ations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will le used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has oeen officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen i. obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to bum lea ves t:tc.) said person is NOT required to complete this
affidavit.
The Department's address, telephone and fax number:
Form Revised 02-23-15
The Commonwealtl of Massachusetts
Department of Ind strial Accidents
1 Congm s S1reet
Boston, MA 1)21 \4-2017
Tel.# 617-727-4900 ext. 7+06 or 1-877-MASSAFE
Fax# 617-727-7749
www.mas: .gov/dia
.,
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street• Municipal Building
Northampton, MA 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation ("OCABR") regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes, a contractor must be registered as a Home Improvement Contractor ("HIC").
M.G.L. Chapter 142A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units .... or to structures which are adjacent to such residence or building" be
done by registered contractors.
Note: If the homeowner has contracted with a corporation or LLC, that entity must be registered.
Type of Work: Est. Cost: -----------------------------
Address of Wark: --------------------------------
Date of Permit Application: ___________________________ _
I hereby certify that:
Registration is not required for the following reason(s):
_ Work excluded by law (explain): ____________________ _
_ Job under $1,000.00
_ Owner obtaining own permit (explain): ___________________ _
__ Building not owner-occupied
_ Other (specify): ________________________ _
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L. Chapter 142A. SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT. SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts
DEPARTMENT OF BUil DIN(; INSPECTIONS
212 Main Street• Municipal Building
Northampton, MA 01060
Massachusetts Residential Building Code
Section 110.R5.1.2
Homeowner: Person (s) who own a parcel of lane on which he/she resides or intends to reside,
on which there is, or is intended to be, a one or ~'o 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.
Section 110.R5.1.3.1
Any homeowner performing work for which a bu ilding permit is required shall be exempt from
the licensing provisions of 780 CMR 11 O.R5 , provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
Such homeowner shall submit to the Building Ofticial, 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 fm which this permit is issued.
Also be advised that with reference to Chapter 152 ( Norkers' Compensation) and Chapter 153
(Liability of Employers to Employees for injuries no·: resulting in Death) of the Massachusetts
General Laws Annotated, you may be liable for p rson(s) you hire to perform work for you
under this permit.
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