24D-014 `.-- Massachusetts - Department of Public Satet)
1 Board of Builder! Re2ulations and Standards
-0 Construction Supervisor License
License: CS 59132
Restricted to: 10
DAVID J OUIMETTE
PO BOX 1038
EASTHAMPTON, MA 01027 ,�
- -- .....-- Expiration: 3110/2012
t .�nuni�si��ner Tr#: 18393
�\ Office .-6-4-e-- mrAffa 6d `eZ V ul l ati ae
s�ness Regultion
- Y �,", HOME IMPROVEMENT CONTRACTOR
p7 =_ i = Re 1079
��1 Registration: 107988 Type:
` Expiration. 811.1 /2012 DBA
BUD REMODELING
DAVID OUIMETTE
PO Box 1038 f 12 Duda Drive
EASTHAMPTON, MA 01027
Undersecretary
3
Alw
TRAVELERS J
uF� WORKERS COMPENSATION
AND
3. EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: ( 6KUB-0322M72-6-1 1 )
RENEWAL OF (6KUB- 0322M72 -6 -10)
INSURER: THE TRAVELERS INDEMNITY COMPANY
1 NCCI CO CODE: 1
INSURED: PRODUCER:
OUIMETTE, DAVID J. DBA FINCK & PERRAS INSURANCE
BUDGET REMODELING 6 CAMPUS LN
P.O. BOX 1038 EASTHAMPTON MA 01027
EASTHAMPTON MA 01027
Insured is AN INDIVIDUAL
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 09 to 09 - 24 - 12 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
m = B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Offinmem
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
0.--- COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
a�
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY .
DATE OF ISSUE: 09 -06 -11 WC ST ASSIGN: MA
OFFICE: ORLANDO INDUS AFF 161
PRODUCER: FINCK & PERRAS INSURANCE 28XPP
000032
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City of Northampton
Massachusetts '
s 1
� w DEPARTMENT OF BUILDING INSPECTIONS u a,
212 Main Street • Municipal Building "fi '~
Northampton, MA 01060 r r'
INS PECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 any 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 backfili), 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
•
The Commonwealth of Massachusetts
Department o f Industrial Accidents
" 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): - P 4v, e.,/ r3// 73,.
Address: / a 3 S'
City /State /Zip: f,,�,,, , ,9. a/ (71,1 7 Phone #: .5;2 ?- S'y ,2
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. New construction
employees (full and/or part- 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 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ 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.
1- 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: 77 Ti 4 e-RS ZP73 ✓i
Policy # or Self -ins. Lic. #: G /,; a 15 P 3 a /'R 7 - 6 "!/ Expiration Date: '9 c) L`_ /
Job Site Address: /.5- //"y s 116 City /State /Zip:///we,Th,q. �/ /Of/.
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 perjusy that the information provided above is true and correct.
Signature: /0 41 n.tJaG Date: a--5--//
Phone #: S 7 -s
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 Applicabll ❑
Name of License Holder : 27,9 4,/ r7.2 V (7L. T7, ,
License Number
/ 2 i ` 4 7 ° Fh. 44 / ! 1 4, dred.7 3 - / 6 2 - 6 2 e 9 / 0 - - -
Address
", Expiration Date
/
Signature (/ (� �-^ p
Telephone
O;Negis�r-.ed; . of a iiiproyeirien oiifra` or; g ., f xa, , :.<AM „ t " M4" ,, Not Applicable ❑
73 p /'47 7 9 FM S'
Company Name Registration Number
. 7 7 c Tad x ' 3 " ?—//- c►ja.,
Address . Expiration Date
72. 9.. are Telephone .3 7
1 SECTION 1U WORKERS' COMPENS%ITION INSURANCE AFFIDAVIT (M G I_ 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 buildin permit.
Signed Affidavit Attached Yes l No ❑
i" ` & p I.lfl
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
•
4
S ECTION 5." DESCRIPTION OF PROPOSED WORK (check'allaDplicable) , y ,,
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
O r Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [(
Brief Description of Proposed
Work: 7l L-. 'aP6 /ham )L' / Tin (; 73A r/7",(7,- , / -
Alteration of existing bedroom Yes r/ No Adding new bedroom Yes Y No /
Attached Narrative Renovating unfinished basement Yes c7 No
Plans Attached Roll - Sheet
6a',1 ew house and.oi add�tioin o ex>ISti . "ous complete he6fol owing:
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
t.SECTION Tai OWNERAUTHORIZATION 70 BE COMPLETED WHEN
OWNERSAGENT OR CONTRACTOR,AP,PLIES FOR BUILDING PERM1T'
_,... ..,: ,.. ,
I bbl 1 h /r Vw , as Owner of the subject
property
hereby authorize p "' I t
to act on m beh , i; all m- ers relafv 2 0416-
work authorized by this building permit application.
Api Signature of rrer ' Date - ' - //
1 7yq , 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 r� ' � -- �--
/� '" ��c.c�rit�- . /tom -as°
Signature of Owner /Agent Date
■
., ...
..ms...
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
r "ii
Existing Proposed Require 1 by'Loning
This col to be filled in by
Buildingepa�kment
, e.- i
Lot Size 1 J
Frontage ` ,
Setbacks Front I E
Side L:;-- 11 R:' L: . i R:s i I 1
= Rear 1 !
Building Height i
Bldg. Square Footage t---1 % 1 = .
-
Open Space Footage % i
(Lot area minus bldg & paved i i
parking)
# of Parking Spaces E
Fill: —. �_ I _ — r _r
(volume & Location) 1
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:! i
I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book i Page and /or Document #1
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 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.
•
E �`'C Dest#meratlJSe n(
ity of Northampton
uilding Departmentu
�C 2 a 20 212 Main Street Se el ep t tab l ew �� .
Room 100
o ,* ° f'JO i ampton, MA 01060
e413-587-1240 Fax 413 -587 -1272
O er�pec► t � -� �_�'{
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 PropertvAddress:,
Map Lot Unit
/S ' • B ��° : x��� 1 �?�
Zone : Overlay District �t
Im St. .District _ b ... CB District . r
SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 wner of Record:
/6h &q ,rL l��yi i �lY} bi alb
Name (Pri CurreMi+iiling Address:
h 413 S 7)_'
Telephone
Signatu
2.2 Authorized Agent: -
� d .T O /fir'' 772 ! j%,v:r;. 4 id's ► ?
Name (Print) Current Mailing Address:
Signature [/ Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use OnI
completed by permit applicant y
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
°Construion`from (6)
3. Plumbing Burbling Permit Fee
F { �
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2+3 + 4 + 5) /5 � , 00, 017 Check Number 7 2 ,
This Section For Official Use Only:
Date
Building Permit Number Issued. - y `
Signature
Building Commissioner/Inspector of Buildings Date
File # BP- 2012 -0601
APPLICANT /CONTACT PERSON DAVID OUIMETTE
ADDRESS/PHONE P 0 Box 1038 EASTHAMPTON (413) 527 -5469
PROPERTY LOCATION 15 HAYES AVE
MAP 24D PARCEL 014 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filed out ,
Fee Paid 7� �J 9, cgu
Tvpeof Construction: REMODEL BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 059132
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
i molitio • ela
ignature 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.
15 HAYES AVE BP-2012-0601
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 014 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0601
Project # JS- 2012 - 001043
Est. Cost: $15600.00
Fee: $93.60 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID OUIMETTE 059132
Lot Size(sq. ft.): 8319.96 Owner: KELLEY ROBERT L & BARBARA J
Zoning: URB(100)/ Applicant: DAVID OUIMETTE
AT: 15 HAYES AVE
Applicant Address: Phone: Insurance:
P 0 Box 1038 (413) 527 -5469
EASTHAMPTONMA01027 ISSUED ON:1/3/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL BATHROOM
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 1/3/2012 0:00:00 $93.60
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner