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City of Northampton
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' Massachusetts ° r
� � * _ �c
y +, ', DEPARTMENT OF BUILDING INSPECTIONS a � y a : 7,
W 212 Main Street • Municipal Building va. '
Northampton, MA 01060i'' ..
s '
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTIO CKNOWLEDGEMENT
The State of Massachusetts allows the homeowner th right under 780CMR 108.3.4 to act as his /her
construction supervisor. The state defines "Homeown r" as, " Person(s) who owns a parcel on which
he /she resides or intends to be, a one or two family welling, attached or detached structures
accessory to such use and /or farm structures. A pers n 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 s pervisor, to be aware that by doing so you
become responsible for compliance with state b ilding codes and regulations. The inspection
process requires that the building department be ca ed to inspect work at various stages, • .ch include
foundation /footings (before backfill), sonotube oles (before pour), a rouqh b ' • Ong inspection
(before work is concealed), insulation inspecti • (if required) and a fina . ilding inspection.
The building department requires these inspection before the work is c• - ealed, failure to secure
these inspections can result in failure to obtain . certificate o = cupancy until the work can be
inspected.
If the homeowner hires other trades to perform wo (e - rical, plumbing & gas) the homeowner will be
responsible to make sure that the trades hired se e their proper permits in conjunction to the building
permit issued, and that they get their re• ' -d i - pections. Failure of the individual trades to secure
the permits and inspections as require. an DE • the project until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner /r.- dent's signature requesti exemption)
I will call to sche. • e all required building inspectio s necessary for the building permit issued to me.
Date
Address of work location
•
0 The Commonwealth of Massachusetts
____ __ Department of Industrial Accidents
z`i ., y 1 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): Wl t ha,;), S• Ti ` A.o n, & At ::, _
Address: 58 PROA.e7 5Tia_gg - T G.
City /State /Zip: LOgps /A€i Ojos? Phone #: '`//3 S"23 - 4t ooS
Are 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
listed on the attached sheet. 7. ❑ Remodeling
2.111 I am a sole proprietor or partner-
ship and have no employees These sub contractors have 8. ❑ Demolition
for me in any capacity. employees and have workers'
working Y p h'• 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
IS(1. equired.] 5. n We are a corporation and its 10.0 Electrical repairs or additions
3. 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 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. ❑ Other
comp. insurance required.]
*Any applicant that checks box #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 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:
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 fine
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.
✓"
/h
Signature: - 9, torrypit4, Date: /� 0e76 B & - ?d!!
Phone #: //3 SSG '/XS �
- Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Prenith 2. Buildin 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 Applicable ❑
Name of License Holder :
License Number
Address E • ation Date
Signature Telephon- / s
- ..*. -.,x ,.. „». , e�-xsA .,.caea .:. sr. �'r°.."'m`z� .Pa Sy " g x
9: Re • rstered "Home.,lm, royement.Contract at5zE _ � 1 Not Applicable ❑
Company Name Registration Number
Address Expira :. Date
Telephone -
SECTION 10 W • • ERS' COMPENSATION INSURANCE AFFIDAVIT (MG L c 152;-§ "• "
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 ❑
a oin1.P weer ke ption
The current exemption for "homeowners” was extended o include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual fo hire who does not possess a license, • rovi . that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3..1.
Definition of Homeowner: Person (s) who own a parcel o and on which he /she resides or i. -nds to reside; ,on which there
is, or is intended to be, a one or two family dwelling, attache. or detached structures acce : •ry to such use and/ or farm
structures. A person who constructs more than one home i a two -year period sh not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a acceptable to • - Building Official, that he /she shall be
responsible for all such work performed under the building ' • rmit.
As acting Construction Supervisor your presence on the job site '11 be quired 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' C.1 pen ation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Mass. • usetts Genes al Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and ass es responsibility for comp ' . ce with the State Building Code, City of
Northampton Ordinances, State and Local t ng Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
.
SECTION 5= DESCRIPTION OF PROPOSED WORK (check alfapplicable), .,
New House n Addition ❑ Replacement Windows Alteration(s) IT Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks ID Siding [El] Other N
Brief Description of Proposed
Work: 1 NA CAT in
Alteration of existing bedroom Yes No Adding new bedroom _ Yes 2C No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
s If,"New ti`ouse'4iid::orzaddition to "exlstinq lous ,xcomplete,theYollowincl;
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 attach-:2
d. Proposed Square footage of new • • truction. Di • -nsions
e. Number of stories?
f. Method of heating? F -places or Woodstoves Number of each
g. Energy Conservation Compliance. % A asscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is constru '.n within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor be - ■ 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 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
1I ,
-
I, W�� /Any '. ZoMs11A , asOwner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under t 14;,.. he pains and penalties of of perjury.
Will 10 �1 • I At AL
Print Name
�j • - IL ...G- . Ta 1 ?- OG 1RWD ton
\ I Signature of Own Agent Date ,
4
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information q
b
Existing Proposed Required by'Loning
This column to be filled in by
Building Department
Lot Size I _ /
Frontage
Setbacks Front 1
Side L " R: L: R:`
r
Rear i =
Building Height I I I
Bldg. Square Footage l l
Open Space Footage
(Lot area minus bldg & paved ! i i 1
parking)
# of Parking Spaces ! ; 1
Fill: � I i _._.._ i .___.�.�__
(volume & Location) ° ' 1
A. Has a Special Permit /Variance /Fi ding ever been iss -d for /on the site?
NO 0 DON'T KNO 0 YES
IF YES, date issued:'
IF YES: Was the permit re .rded at the Registry of Deeds?
NO 0 fbONT KNOW 0 YES 0
IF YES: enter 'Book Page , an. or Document # 1
I
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT ' OW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commi • ion?
Needs to be obtained ® Obtained , Date Issued: 3
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: I
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
.J �� �v Dep use a aly V k
RE EIVED City of Northampton St t. us of P � . , b � 4
Building Department Ct ut D vew ; er _ " t ''
212 Main Street u ery ep ii ' Itt ^ � � , Ar s - OCT ! 8 2011 = �� Room 100 ' - e11 , - a•tl � �� �,.
Northampton, MA 01060 :501-
` i sT efS r ctur - s7. +. _" op 9 UtbiN G 'Ns on 413- 587 -1240 Fax 413 - 587 -1272 P SI e MA 01060 K �, - C ••M Spe c i fy APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVA OR E OLISH A ONE OR TWO FAMILY DWELLING
S ECTIO N 1 - SIT INF RMATION _
This section to be completed by o ffice
1.1 Property Address:
N
"� .�ya i `� il, cr ' �. _ l : L6 . a " - " -
�l W t U 1 , S S'fRLS HT I.',, N iap x ° " ;Lo � r Unites ,
Zone Overlay District
a x , "'f.. '"R" 1 C I S k C } :. �4 L '
EIm St District CB District F
SECT ION 2 : PROPERTY O WN ER SH I P /A UTHORIZED. AG ENT .
7 2.1 Owner of Record:
I�l�ll�A;„ S T�m sfJw t • o• Lox 1 L�� IIU mA 010S3
Name (Print) Current Mailing Address:
v vM ,.../__ Telephone
Signature / 1/j 5$/_ 400S
\ 2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - E STIMATED CONSTRUCTION COSTS ,_
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) • Building Permit Fee
2. Electrical (b)" Estimated; Total Cost of
"Constructio from (6)
3. Plumbing B Permit Fee:
4. Mechanical (HVAC) ,,
5. Fire Protection .
---If 6. Total = (1 + 2 + 3 + 4 + 5) / 3oo. e°
Check Number ..
. This Section For Official Use "Only
` L7ate
B uilding :Permit •Numbe Issued: '
"Signature _ v !
Building Commissioner /Inspe of Buildings Date
v.
11 WILLIAMS ST BP- 2012 -0405
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 235 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2012 -0405
Project # JS- 2012- 000647
Est. Cost: $1300.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq ft.): 5532.12 Owner: TUROMSHA WILLIAM J
Zoning: URC(l0o)/ Applicant: TUROMSHA WILLIAM J
AT: 11 WILLIAMS ST
Applicant Address: Phone: Insurance:
58 FRONT ST (413) 586 -4005 ()
LEEDSMA01053 ISSUED ON:10/19/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:1 NSULATION
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 10/19/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner