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Office of Consumer Affairs and Business Regulation
a ■ _ �, 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 143023
Type: Individual
Expiration: 6/9/2012 Tr# 298757
DAVID M. CLARK
DAVID CLARK
16 SHEFIELD LANE
FLORENCE, MA 01062
Update Address and return card. Mark reason for change.
Address Renewal I - - - I Employment - I Lost Card
DPS-CM Cr 50M-04/04-G101216
1 e lrr) oii r nil/ a o jf rrr i
Office of Consumer Affairs &Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. H found return to
Registration: 143023 Type: Office of Consumer Affairs and Business Regulation
Expiration: 6/9/2012 Individual 10 Park Plaza - Suite 5170
p
Boston, MA 02116
DAVID M. CLARK
DAVID CLARK `
16 SHEFIELD LANE \— _ _
FLORENCE, MA 01062
Undersecretary Not Valli without signature
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
jermits 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
AF
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
. •
. -.
. ,
. The Commonwealth of Massachusetts
Department of Industrial Accidents
si
•=lirdr...- A. Office of Investigations .
z =.-
600 Washington Street
Boston, MA 02111
www.mass crov/dia
' t,
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name pusineseorganization/Indivirhi.o: DAV t D CLAra-K
• Address: 40 5i4 E 1-FEU) i klE . - -
1.4-49 .& p vo-1...t M A
City/State/Zip: CS t 0 6 2_, - Phone.#: 5 6 9 3 'I 1
Are
you an employer? Check the appropriate box: Type of project (required): /
1.0 I am a employer with 4• 0 I am a general contractor and I
6. 0 New construction
have hired the sub-contractors
employees (full and/or part-time).*
listed on the aftarthed sheet. 7. gl Remodeling
2. I am a sole proprietor or partner-
These sub-contra.ctors have
ship and have no e.oloyees 8. 0 Demolition
enAguyees and have workers' .....
working for me in. any capacity. 9. 0 BuildmI:. atclititin
-
[No workexs' comp. insurance
1 n Electrical repairs or additions
. 5. 0 We are a corporation and its 10.
3.01 am a homeowner doing an work officers have4xeroised their . 11.0 Plumbing repairs or additions •
myself [No workers' comp. nett of exemption per MGL
12.0 Roof repairs . -
insurance required.] t
c. 152, § 1(4), and we have no
•
13.0 r
employees. [No workers' Othe
comp. insurance reqUiXe.d.1 1 e-VJ '510 • IN 6- 4 bkt 0 u..) S
*Any applicant that checks box #1 must also fill out the section below showing their woricers' compensation policy infornation. ': •
t Homeosaters who submit this affidaVit inclicating they are tieing all work and then hire outside contractors must submit anew 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 bate employees, they must provide their workers' comp. policy number.
l ain 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/Statz/Zip:'
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage. as required raider ectialr25A ofMGL c 152 can lead to the iinpOsitlini of crintina1 penalties of a
fine up to 51,500.00 and/or one-year iminiso .1.nent., as well as civil penalties in the form of a STOP wopx-ORDER and a fine
of up to 5250.00 a day against the violator. B advised that a copy of this statement may be forwarded to the Office of
- EVeitiiritionsiifthe -- DrA for insurance coverage verificition.
I do h.ereby_c ell r; - . , - - i , a• 4 -.0 ,, . aides ofperjuryiltat the information providiaTibOv.e ii.triieizniLiop•pct
- - - - w
Sa via. • .. . _ .. . • ilLntare: -- , D I 2- ,
Phone ii: c113 s toqi - .. • •
• 1 . .. . ,....,____
. - Officza I use only. Do not write in this area, to be completed by city or townOffirifil
City or Town:
Permit/License #
Issuing Authority (circle one):
'• ' . . •
.1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electricaljnspector 5. Plumbing Inspector
6. Other
Contact Person: '
Phone #:
•
O SE ¶0 G E Fr' 3 l �"
NreV\? C �p� c�iSt �
1,-A NI 1-0 F, E s� t � � r 1 Gl rs � r! t N Y
Dn�S � �---�- � M °
,car , � DONS.
S
yE ASS
V � �-� GAD 0
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Of- aUIL-PiriG-
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : PAU € 0 0-4 (t( 4 33—
License Number
112 SHE F 1E1_0 LA'J E % l— G° Lc i L
Address pi--e REN CE I 1 A 0(062_ Expiration Date
Signature Telephone 573(a it 3(
4100 ,I �< ,�� r ; &� 1 :1 NotA
, €�.IE a.s`y.ia.ii , - i�a�Q. ��' y Pte &<� s Applicable ❑
bAu' - s III 301 -3
Company Name Registration Number
IL C wc F ''-`t L A + ' .)�'
(, — q — 2-ci
Address F L_e Q E' '`' cc ' /+ C i 6 l "L- Expiration Date
Telephone 5 2> ` 4 7
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 ❑
' ', - 7, 5 4451 1 a
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 -year 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 ❑ Replacement Windows Alteration(s) ED Roofing
Or Doors ® -
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [IA Other [0]
Brief Description of Proposed Re t?Lfl ALL. 'W IN b e(A) S A N b $ i Di NO- • TO tI SE t1, w
Work: S Ali t) C. k. Mekj (No Artib S i p it4Q'
VAlteration of existing bedroom Yes No Adding new bedroom Yes , No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
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
OW NLQ$CONTRACTOR APPLIES FOR BUILDING PERMIT
I DAN i. p h'L utLPE -1 , as Owner of the subject
pro R�
her- •
WWI i> C t. P1 IZI
to --- -, •ehalf, in all ma e - lative to work authorized by this building permit application.
i 2. %L —
• .• - Owner Date
DAJLQ r\U &P itY D.Avtp Cu4a
, as Owner/Authorized �
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of..rny.k
and belief.
Signed under the pains and penalties of u
9 P P perjury.
DiAvi0 aPA
/2 - iZ Z //
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 Depatltmetil
Lot Size s 1 - 1 ! i
h
Frontage I i
Setbacks Front F i
Side L:i { R:1 i L:1 s R: 1
Rear = = 1
Building Height
i
Bldg. Square Footage ""'-" 1 % 7 ;
Open Space Footage a %
(Lot area minus bldg & paved # z 1 I t__.e.._..., ,
parking)
# of Parking Spaces = 1 d ~ -~-
Fill:
(volume & Location) la
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
`"" NO 0 DONT KNOW 0 YES 0
IF YES, date issued: 4
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW O YES 0
IF YES:—enter Book r i Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission? 1�', A.
Needs to be obtained 0 Obtained ®
, Date Issued
C. Do any signs e}cist on the pprq�erty? YES NO 0
IQ e C:if t?NG �-
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 O
IF YES, describe size, type and location: ILA.
E. Will the construction activity disturb (Gearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required. h) q , A k
•
•
.� �.
City of Northampton
.� V\\ : uilding Department
`
212 Main Street
ssec Room 100 b,
010 ■ 14. ' ° Northampton, MA 01060
phone 413 -587 -1240 Fax 413 - 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
1 ' ► Cc NZ. Z `j'
Map Lot Unit
Zone Overlay Drstrct
Eim Bt. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
V 1,0 M) R. P Y y coi.12 sT:
„at�1r�ti Current Mailing Address:
Ka(rr+- Pro 1 "'\ A s S 0 0 6 0
• Telephone
Sign.. -
2.2 Authorized Agent:
A v i D G 1.- r4 2 K l b S ra Li4wy'E
Name (Print) Current Mailing Address:
t' Il ASS 01 O 6 2
Signature Telephone S (o
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ' 2 , c0 U • C (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 -7
6. Total = (1 + 2 + 3 + 4 + 5) 1 Check Number J �� � ! CJ
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date