17C-058 ,•�
u A
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 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 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 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
Oft
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The Commonwealth of Massachusetts
,:.w" "°" Department of Industrial Accidents
ir r, ,�-- Office Of Investigations
a 600 Washing on Street
., -w Boston, MA 02111
� ; ,..,-7,,, www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /EIectricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): (Aie -6 Pt !v 9A 56 /QS
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. 7.1 I am a employer with (, 4. 0 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. El I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. n Demolition
working for me in any capacity. employees and have workers' 9. El Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
q ] officers have exercised their 11. exemption per Plumbing repairs or additions
3. ❑ I am a homeowner doing all work right of i MGL ❑ � g p
myself. [No workers' comp. 12.[] Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.E 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 cent' - under the pain and penalties of perjury that the information provided above is true and correct.
II
1 Signature: A V_ _ , �_. .. _ Date: Z S L?
Phone #:
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):
1. Board of Health 2. Building 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 : /6 lJr;� tiK-4 -- /() C5 9'
License Number
Address Expiration Date
Signa ur, Telephone
9. Registered Home Improvement Contractor ...,. Not Applicable ❑
/./ V).3w t > . /Gse3 t>
Company Name Registration Number
Address Expiration Date
4t TelephoneV2' " 2 Z
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 Ower_Exemptlla
The current exemption for "homeowners" was extended to include Owner occupied Dwellings of one (1) o(2) families
and to allow such homeo r to engage an individual for hire who does not possess a license, prov' that the owner acts
as supervisor. CMR 780, Six Edition Section 108.3.5.1.
Definition of Homeowner: Person who own a parcel of land on which he /she r ' s or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached ores accessory to such use and/ or farm
structures. A person who constructs more than one home in a tw r period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on • • acceptable to the Building Official, that he /she shall be
responsible for all such work performed under • 3 uilding permit.
As acting Construction Supervisor your • ence on the job site will be required from time to time, during and upon
completion of the work for which t . ermit is issued.
Also be advised that with ref- ce to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perfo ork 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
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks [[] Siding [DI Other [O]
nef Description of Proposed
/Work: % ti f ✓ /,!h , ! A44-Le
)
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
t
L7 N I in , 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 — - - Date
I ' `= ' si�� c v r , as Owner /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 the pains and penalties of perjury.
Print Name
Signature of Owner /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
Rear
Building Height
Bldg. Square Footage o/ __, .„
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces —°
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for/on the site?
NO 0 DONT KNOW YES
IF YES, date issued:.
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW to YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES (3 NO
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
9\
IF YES, describe size, type and location:
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 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
1
Depa rtment use only
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City of Northamp Status o Kermi
Building Department Curb i3 Pe
^U 212 N(ain Street ' pbiht
� �� ; ''\j ' Room 100 s e erNl�eat v allal a tlrty ,
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Nort MA 01060 T Sets ofStructura Pl " 0,
-
¢ phone 413- 587 -1240 Fax 413- 587 1272 Plat/Site Plan
Ot her Sper fy
APPLICATION T O CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE O TWO F DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to b e co mp leted by office
Map Lot Unit
/_ � ��7 «�`"" ' Zone Overlay District
l ei z'`�C 6 ' / ' O Elm -St District CB District
SECTION 2 - PROPER OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
2.:
Name (Print) Current Mailin Address:
Telephone
CSi n --
2.2 Authorized A�1ent:
Gtra ��� S o ros
- 58 � L 6RT� Sr SP`
Name { �nnt ) i � C urren t Mailing Address
x � - 7 3 39 2 2
Signature Telephone
SECTION 3 - ESTIMAT CONSTRUCTION COSTS
Item Est Cost (Dollars) to be Official Use Only
completed by permit applicant
Permit Fee
/( Building
B uilding
26e, (a) Building
2. Electrical (b) Esti Total Cost o
�
Construct from (6)
3. Plumbing Building' "Fee
4. Mechanical (HVAC)
5. F Protection
6. Total= ( +2 + +4 +5) Check Number � 3�coa '
This Section Fo Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File # BP- 2009 -0836
APPLICANT /CONTACT PERSON URBAN & SONS INSULATION CO INC
ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD (413) 732 -3922
PROPERTY LOCATION 190 CHESTNUT ST
MAP 17C PARCEL 058 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Paid 6a6x
Typeof Construction: INSULATE ATTIC & WALLS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 100590
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION 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
Ot-iiISIO 2
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.
190 cagsmur grd BP 2009 - 0836
GIS #: COMMONWEALTH OF MASSACHUSETTS
v : t - t)58. 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 -0836
Project # JS- 2009 - 001242
Est. Cost: $2761.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 100590
Lot Size(sq. ft.): 14897.52 Owner: WHITTIER SARAH JANE
Zoning: URA(100)/ Applicant: URBAN & SONS INSULATION CO INC
AT: 190 CHESTNUT ST
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732 -3922 WC
SPRINGFIELDMA01104 ISSUED ON:4/15/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE ATTIC & WALLS
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 4/15/2009 0:00:00 $55.003262
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo