04-018 (5) City of Northampton
Massachusetts '°
r
� DEPARTMENT OF BUILDING INSPECTIONS r a + ,
212 Main Street • Municipal Building a.
! Northampton, MA 01060 y 1
INSPECTOR
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 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
•
The Commonwealth of Massachusetts
• Department of Industrial Accidents
Office of Investigations
.�! 600 Washington Street
y r xrs 'r
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
f R
Name (Business /Organization/Individual): (kO Nr�`c� M e
/e,
V
Address:
City /State /Zip: Phone #:
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 6. New construction
employees (full and/or part-time).* have hired the sub - contractors
listed on the attached sheet. 7. El Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have g. 1119emolition
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
q ] f
officers have exercised their 11. Plumbing re
3. ❑ I am a homeowner doing all work h id hi
❑ g airs or additions P
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' 13.0 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:
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 un�kw epains and penalties of perjury that the information provided above is true and correct.
Signature: gn Date: 2–// Z—
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
g
8.1 Licensed Construction Supervisor: Not • Appl . - . t P le ❑
.4,,
Name of License Holder : l � v t/ /S ✓ / 't d/�-7647 4 /3 7 7 /
License Number
Se) f et, c� r // R /?6- // / 9 /z° `(3
Address Expiration Date
k!/ /� / �.s. ! / r /U P
Signature r- / Telephone
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2 4, - z 2_ S2 2 - a/
9.mR ' s e ' d Home ImprovemenfiGontraetor. � _ e ,. ,; a - 4, 2 Not Applicable ❑
/-c.• r✓ ,° s T 77
Company Name / Registration Number
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Address Expiration Date
Gc, r / � G 4 r a ^ � s � � n f e 1 ' t Telephone Z S L_Y U /` %
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G,L c 152, §25C(0)
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 r eme w
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
•
a
SECTIONS- DESCRIPTION OF PROPOSED WORK (check all applicable) .
New House ❑ Addition E r l Replacement Windows Alteration(s) ri Roofing pi
Or Doors D
Accessory Bldg. ❑ Demolition n New Signs [0] Decks [C] Siding [0] Other [0]
Brief Description of Proposed
Work: 60 ✓Y.syTk_c�c `� S. _, t ..--t / 04;3 c OciX e fe Ai /, „0,,z, °,- b ,,..„,,...„_, / eV' fe-
/ / c !e,
Alteration of existing bedroom Yes V No Adding new bedroom Yes 1/ No V
Attached Narrative Renovating unfinished basement Yes »�-' No
Plans Attached Roll - Sheet
6a f N"ew icdiise iitiZeiddit on _existinq=housinp comp lefe theTfollow riq:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: 4 Number of Bathrooms Z
c. Is there a garage attached? ri--S
d. Proposed Square footage of new construction. Dimensions l Z- >' / 7
e. Number of stories? O ,
f. Method of heating? ,T'11 44./ Fireplaces or Woodstoves Number of each '
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction 4,6P-167G/ /No. i. Is construction within 100 ft. of wetlands? Yes Is construction within 100 yr. floodplain Yes ✓ No
j. Depth of basement or cellar floor below finished grade J / /
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank ✓/ City Sewer Private well ■/ City water Supply
SECTION .7a.L. OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT 0 r ONTRACTOR APPLIES. FOR BUILDING PERMIT -.
( '/ / , as Owner of the subject
prope '
hereby authorize
to act on my
be, al in a� atte : elative to work authorized by this building permit pplication.
/1 ' dt.■
Si gnat re f Owner r Da
I, vts A-67 7C d ,-c--, , 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.
I
Print Name W
.�+ /// f� ._-
Sig ure of 0 er /Agent Date i
._
J
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by'Lontn
This column to be fill)*
Building Department (t 7
t.
`
1
.
Lot Size F ;
3 a
Frontage ----
Setbacks Front s e 1 c 1
Side L: 77-51 R:' 113'1 L::: r R: ° A` i ?
Rear 17
Building Height f 1 7
Bldg. Square Footage i % i i j°
Open Space Footage _ %
(Lot area minus bldg & paved i i a
parking) -
# of Parking Spaces
Fill: --_ _.___ __ _____ .__ . ..._ ._. _ . _._�_._ _ ___ ____ __ __ __
(volume & Location) 1! I -
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO e DONT KNOW 0 YES 0
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I I Page; I and /or Document #1
i DONT B. Does the site contain a brook, body of water or wetlands? NO KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ® ,Date Issued:
C. Do any signs exist on the property? YES 0 NO el
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
3
IF YES, describe size, type and location: i ;
E. Will the construction activity disturb (clearing, grading, ex ation, 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.
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VET -----a,',,,,.,, o Departmeet use only �M
" � as -i tea. r 3.t ;; S
�� ity o f Northampton Stat of P mit 'e Itt` - " ' , � `
• � :wildin Department Curb �Cut ri a Permi . • w
`32 2 212 Main Street S ewe r Sep icAyailabill: � .. " ' � , ,
v° i sle
F� Room 100 Water e!I'Aiiiaeillty ' ',�!!. , _ . t
ort ampton, MA 01060 T rio ,,, s ofS ru taro ° a ` -r -
�� - 587 -1240 Fax 413- 587 - 1272 P�S- e a ns
' Other . y -4`-a ,, ' ,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.1 Property Address:
This section to be'comp by office • A /� ' ' .Lot ! £ Unit '
//v.i.7 ° -Y •-f-e---4- Zone - Overlay Dist
Elm St. Dsfr�cf ? CB District- `
S 2,- PROP OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing A r s: --
X � w � �-- -- Telephone ` `
Si g natu o
2.2 Authorized Agent:
Zo c/ e...<
/�cr� t6.47) r r r n G . Lac j�S'/ 4v, /.�.�v s :ljr /N,9
Name (Print) Current Mailing Address:
Signature Telephone
SEC - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use .Oniy . : , ,,:
completed by permit applicant
1. Building (a) Burlding'Permit Fee
Co _..,s—‘ a 2 . Electrical Z5'0 O o , (b), Estimated .Total Cost of
Construction from6) ....
3. Plumbing �� Building Permit Fee
4. Mechanical (HVAC) ' yDdU ed
5. Fire Protection 7
6. Total= (1 +2 +3 +4 +5) .5��O4O Check Number �°
Thi >Section For Official Use Only
Date
Buildings Permit Number: Issues:
Signature
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0691
APPLICANT /CONTACT PERSON LOUIS MONTGOMERY Q ��,�,✓
ADDRESS/PHONE PO BOX 951 WILLIAMSBURG (413) 268 -2028 0 ,^'""
PROPERTY LOCATION 533 AUDUBON RD
MAP 04 PARCEL 018 001 ZONE RR(100) / /WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ��a y(� j Y C
Fee Paid `!7 Y� o
Typeof Construction: CONSTRUCT 12 X 17 4 SEASON PORCH OVER EXISTING DECK & CONSTRUCT 12
X 12 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 013471
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
I - n oliti • ' ay
Si: a - • f 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.
533 ALr ' - MN RD BP- 2012 -0691
GIS #: _ COMMONWEALTH OF MASSACHUSETTS
Map:13� 04 - 018 CITY OF NORTHAMPTON
Lot: -00' PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catel I)1TION BUILDING PERMIT
Permit # BP- 2012 -0691
Project _ JS- 2012 - 001217
Est. C‘:s 1000.00
Fee: � PERMISSION IS HEREBY GRANTED TO:
Const. c Contractor: License:
Use Gr .. LOUIS MONTGOMERY 013471
Lot Sizci i.): 47916.00 Owner: PHELPS HENRY & JILL M
zonii _ 100) / /WSP Applicant: LOUIS MONTGOMERY
AT: 533 AUDUBON RD
App( + ildress: Phone: Insurance:
PO l ) 1 (413) 268 -2028 ()
WILL, 7,BURGMA01096 ISSUED ON:2/10/2012 0:00:00
T(. 7 FORM THE FOLLOWING WORK:CONSTRUCT 12 X 17 4 SEASON PORCH OVER
EXI S DECK & CONSTRUCT 12 X 12 DECK
POs " ' `' CARD SO IT IS VISIBLE FROM THE STREET
Insp. lambing Inspector of Wiring D.P.W. Building Inspector
Underr Service: Meter:
Footings:
Roue Rough: House # Foundation:
Driveway Final:
Finn' • Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rout: Oil: Insulation:
Finn' Smoke: Final:
THl IIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
AN'. "S RULES AND REGULATIONS.
Cer of Occupancy Signature:
Fee': Date Paid: Amount:
Bui!.' 2/10/2012 0:00:00 $198.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner