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1,1 ' "–� DEPARTMENT OF BUILDING INSPECTIONS , _'-3 f - /=
INSPECTOR 212 Main Street •Municipal Building 'c . o,,
V S` .
Northampton, MA 01060 .
,r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as Lis /her construction sup:: sor. The stat-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
1 made
/ I, 3d G- n J�4 ( ;�
_ , understand the above.
(Home owner /resi gnature requ ing exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
-
. .0 The Commonwealth of Massachusetts
Department of Industrial Accidents
1.— ' Office of Investigations
���Ic
°— 600 Washington Street
4 •"9:14—
Boston, MA 02111
_4° ° www.mass.gov /dia
I. Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual):
Address:
City /State /Zip: ne #:
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. El I am a general contractor and I
employees (full and/or part -tiine).* have hired the sub - contractors 6. ❑ New construction
listed on the attached sheet. 7. modeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. E rDenolition
working for me in any capacity. employees and have workers' 9. El Building addition
workers' comp. insurance comp. insurance.
f
uired.) 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. m a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
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 applic that checks box #I must also till 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 providi workers' co pensation 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
Investinations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
• attire: .fit Date:
i�
Phone # 1 t ' i J
Official use only. Do not write in this area, to be completed by city or town offtciaL
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 - CONST UCTION SERVICES
8.1 Licensed Construct' Su ervisor• License Not Applicable Number U'
Name of License Holder
Address f Expiration Date
Signature / Telephone
9.Reclistered Ho I "mprovement:Gorrtractor _ � a .. . Not Applicable
Company Name \ Registration Number
\ 7
Address / . Expiration Date
f \ Telephone
1 `
SECTION 10- WORKERS' COMPENSATION INSURANCEAFFIDAVIT (M.G.L. c. § 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 Wi er lY ptia
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 C -
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing E
Or Doors D
Accessory Bldg. ❑ Demolition 1 New Signs [l ] Decks [[] Siding [C:1] Other [O]
B rief Description of Proposed / � B Lb Cjt /.t� /N ;fJ ✓Work: // 0
Alteration of existing bedroom Yes 1/ No Adding new bedroom Yes No I
/
Attached Narrative Renovating unfinished basement Yes �o
Plans Attached Roll - Sheet
4. house d it addition to existiic houiirt aoiripfet tkle.fotiowrna:
a. Use of building : O mily Two Family Other
b. Number of rooms in eac family unit: Number • :athrooms
c. Is there a garage attached ? '\ \
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? r
f. Method of heating? \ Fireplaces or Woodstoves Number of each _
g. Energy Conservation Complian • . Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within lo . ft. of wetlands? Yes lo. s cons ruc io WI ire - 1 - 00 yr. ffoociptain Yes - No
j. Depth of basement . cellar floor below finish-. grade
k. Will building con •rm 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
I, , 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 Owner Date
I, , 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.
__
y S Pri t Name
ignat • e of Owner /Agent Date
R ,
NW
AV
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 __ ..., __ _ M___ _...._._.._____ --
Frontage _ _ .
Setbacks Front
c ry
7i- • #
Side L:...,/- R: L: R:
Rear _
A
Building Height . 7
Bldg. Square Footage Or fi
Open Space Footage
(Lot area minus bldg 8c paved
parking)
# of Parking Spaces
Fill: i —
(volume & Location)
A. Has a Speci I Permit /Variance /Finding ever been issued for /on the site?
y
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES
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 V
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 V
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excav n, 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.
Department rise only
City of Northampton StatusofPern t
Building Department
212 Main Street
Room 100
Curb CutLDnrre Eermrt
S ewer S ep Uc u a ilabrlrty i �
ylfater/4Ve[I ' _
Northampton, MA 01060 FviroSetsofSUucfur
phone 413- 587 -1240 Fax 413- 587 -1272 Pi Plans
Ot her'Sp ecify .;
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 r P � roperty AA Av 1 5 2�,(j
3 l �i c3 / /huge.. 5 til Map a Lot Un
4/0$14/1,1P ���� 14 O 64 ri or f " v,fir` ISk i ts Overlay District
n ^ '
N
t .Elm St. District CBpfstrict
/2.1 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
Owner of Record:
1770fAi c • KAY c5 p /Av/reL 8 7 7 /1/%. ,r ?nr ,Or.
Name (Print) Current ailing Address
T — 1 /
L .,.... �,,-- IEio e
Sig ure
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building /112 0 D• ( briA•) (a) Building Permit Fee
2. Electrical J (b), Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) .' Aid. ' , ' Check Number a, ,1(,`! / • 1r
This Section or Official Use Only
Date
Building Permit Number. Issued:
I
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2009 -0991
APPLICANT /CONTACT PERSON RAY JOAN C
ADDRESS/PHONE 37 LAUREL ST NORTHAMPTON ,
PROPERTY LOCATION 37 LAUREL ST
MAP 38A PARCEL 052 001 ZONE PV/URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 1,( n0
Fee Paid c)790 4
Typeof Construction: DEMOLISH BARN
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE F LOWING 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
Demolition Delay '� el
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.
i w
BP- 2009 -0991
GIS #: COMMONWEALTH OF MASSACHUSETTS
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 -0991
Project # JS- 2009 - 001435
Est. Cost: $1200.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 26397.36 Owner: RAY JOAN C
Zoning: PV/URB(100)/ Applicant: RAY JOAN C
AT: 37 LAUREL ST
Applicant Address: Phone: Insurance:
37 LAUREL ST
NORTHAMPTON ,MA01060 ISSUED ON:6/1/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: DEMOLISH BARN
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 6/1/2009 0:00:00 $20.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo