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it
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
- - - - - - - permit -s- in- conj 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
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
A- =W 1� r Office of Investigations '
, 600 Washin Street
Y - I Boston, MA 02111
�• '. ' www.mass gov/dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information /J Please Print Legibly
Name ( Business /Organization/Individual): / ; S . ,c y (ZYtrre,t e7'7,4,
Address: y. eo;�l✓, y
City /State /Zip: / tnf 7r�
- J l - f /` 0 o ) - / 4/0-( Phone #: 4 /f.. 3 -C C / r
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
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. 0 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 c omp. insurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
ofc_ershaveexeercised it _- 1- bin repairs or additions
3.0 I ama homeo-wacr doing-all-work- B -gl g epairs
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' 13.0 Other
comp. insurance required.]
*Any applicant that checks box #1 must 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.
Iam an employer that is providing workers' compensation insurance for my employee& 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 f T''
of up to $250.00 a day against the violator: 13e advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
p do hereby certify under the p ,.• � * d penatfips of pedury that the information provided istrue andicorrect
Ii _
Signature: 7- ��,.., >1� - - Date: f i S/0 7
_
Phone #: "ii 3 - - 6.2 6 --7 7?' 7
Official use only. Do not wrrte in this area, — to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
I Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector ._
6. Other '
Contact Person: Phone #:
r
s
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : / i 444/, Y / t J !J
License Number
Address Expiration Date
41/3 — ea& ""/77
Signature Telephone
9.; Recestered ,Home.lmprovementContractor ' ...._ : Not Applicable ❑
et jiciyis.71 4,44 Jt774'i- A27
Company Name Registration Number
//3 (vN: 47 yr� // �ro
Address Expiration Date
�i✓ .77n/e.--7 /y4 Telephone - /7`l7
. ............................... .
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 ❑
1 oiue _ ue xem s Lion
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 ` 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.
M acting Construction Supervisor your presence on the job site will be required from time to time, during and npnn
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
o ampton • r• mances, , • , • ttsGeneral- Laws- Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [l Addition ® Replacement Windows Alteration(s) Roofing ❑
Or boors D
Accessory Bldg. El Demolition ❑ New Signs [El] Decks [D Siding [O] Other [❑]
Brief Description of Proposed
Work: /' 'K /6 1- 47,(if fiCAs ) f oi&H NalSA - -
Alteration of existing bedroom Yes No Adding new bedroom Yes 14 No
Attached Narra ' Renovating unfinished basement Yes ( No
Plans Attachecoli) - Sheet
sa °'If Ne into se mitt* addit o .toeiasitha heuelrfa oinplete.the fella d:
a. Use of building : One Family is Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms 2_
c. Is there a garage attached? )(i
d. Proposed Square footage of new construction. 2 Z Dimensions l9X /6
e. Number of stories? I
f. Method of heating? ti/cf../,f' Fireplaces or Woodstoves ,r/v vR Number of each
g. Energy Conservation Compliance. N/A Masscheck Energy Compliance form attached? ,c1/4
h. Type of construction JU 'g ,r+l,
i. Is construction within 100 ft. of wetlands? i Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade Ai/el
k. Will building conform to the Building and Zoning regulations? > Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/"/� �K�,.¢ L , as Owner of the subject
property
hereby au horize .r/lad., s ,.7.✓77Z..1C77"4-
to act on y behalf, ' all matters lat',j r• rk authorized by this building permit application.
���`` / Z —( —
Signa -re of Owner Date
I, / / /ye- / ✓,Cy , 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 L. _ .,t-- f/:7_i? .,.. _.. _ .__ .._:_.` ..2 ._ +t _ ._ _..
Fronta It 7 5 _ /.Z,.. _..__ . ___..____ ..._
Setbacks Front _.
Side L..`z R: 3Q. L:! c R ,3_.
Rear , W --
Building Height __ _.
Bldg. Square Footage I °" ' % FIETI, —
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces La:
Fill: (volume 8c Location) w V _ . ` . -----....- .-.,.µ _ -_--, [[ ' /
A. Has a Special Permit /Variance /Finding ever been issued for /on the site? !�
NO 0 DONT KNOW 0 YES
IF YES, date issued: mMV _. M 4:X
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book 1 1 Page i and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO '010 DONT KNOW 0 YES i
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained , Date Issued
C. Du any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
— ' - - r dra i PrP are rn `nsar an P5 _n nr a. _itinnc n s ns intPn e i fnr tip rn ert 7 YFS 0 N O
Y P p- -- g f� P y
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton 5t� Peat r
Building Department C. Dperarrrat
212 Main Street Se �•,4yag
Room 100
Northampton, MA 01060
phone 413- 587 -1240 Fax 413- 587 -1272 • Pna , e 4 p , 7 r `
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 completed by office
4".9,zi), ✓,'44. L1,4 y Map Lot Unit
+,fi Zone " "' Overlay District
Elfin St. District CB District
SECTION . 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
- — _ pret 4,t2.124(
Name (Print II / Current Mailing Address:
� Telephone
Signatu - -
2.2 A thorized A ent:
� r✓ '/ 3 4. J7Y /& � A/ � .✓G - T c�c
Name (Print) Current Mailing Address:
" � 5-- 7 69, 3 o crra _ 72"7"
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building j ;2i `'"
(a) Buildin Perrnit Fee
QUO-
2. Electrical k. (b) Estimated Total Cost of
./-10 O. U U Construction from (6)
3. Plumbing Building Perm Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total (1 + 2 + 3 + 4 + 5) Check Number 1;57
_. _ TTTIII
This Section ForOfficial Use Only
Date
Building Permit Number :, Issued:
Signature:
Building Commissioner /Inspector of Buildings -- Date
File # BP- 2010 -0610
APPLICANT /CONTACT PERSON TIMOTHY SENEY
ADDRESS /PHONE 43 COUNTY RD HUNTINGTON (413) 667 -0230
PROPERTY LOCATION 140 CARDINAL WAY
MAP 36 PARCEL 331 001 ZONE SR(100) //WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 8351 ���
Fee Paid
Typeof Construction:_ DEMO EXISTING DECK & CONSTRUCT 14 X 16 3 SEASON ROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 061088
3 sets of Plans / Plot Plan
1 j e THE, OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I RMATION 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
......____,L,....„.„9
iy21 / 0 9
Signature of Building fti al
g 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.
140 CARDINAL WAY BP- 2010 -0610
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 331 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit # BP- 2010 -0610
Project # JS- 2010 - 000889
Est. Cost: $29200.00
Fee: $112.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY SENEY 061088
Lot Size(sq. ft.): 19558.44 Owner: MCDONALD KEVIN M & JENNIFER H
Zoning: SR(100) //WSP II Applicant: TIMOTHY SENEY
AT: 140 CARDINAL WAY
Applicant Address: Phone: Insurance:
43 COUNTY RD (413) 667 -0230
HUNTINGTONMAO1050 ISSUED ON :12/23/2009 0 :00 :00
TO PERFORM THE FOLLOWING WORK :DEMO EXISTING DECK & CONSTRUCT 14 X 16
3 SEASON ROOM
•
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter: 0 f U l
Footings: LY1� Y
Rough: Rough: / /i House # Foundation:
� "ilia p�''' Driveway Final:
Final: Final: 6_ 30 J t
Rough Frame: (0 rc PC Fi D 1
(.4t, MC CA 5( +J‘f ,f
P11,50 j61 5T N Ci s 4
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:OK 1 P)6 .)` 5
Final: Smoke: Final: c( 17 1 . / 6
THIS PERMIT MAY BE REVOKED BY THE CITY OF- NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND RE /!
Certificate of asi Signature: C7
FeeType: Date Paid: Amount:
Building 12/23/2009 0:00:00 $112.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - ;\nthony Patillo