23A-226 • r �,• -
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
i.:•ermits 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
Date
Address of work
location
0 ,
,.. . .. -.-- ..
'•
. The Commonwealth of Massachusetts
_,— Department of Indust l Accidents •
Office of Investigations •
• =._ ,=--- .....
600 Washington Street
tt. •=11:fet,=. '. 47 Boston, MA 02111 .
''''•; -
- -- , r•o . ' www.mass ovv/dia . ....
•
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name pis inesslOrganization/IndivichinD: 1-/A / coAffaeme, -
Address: /5 5 C.-Z.A),)9/1-4,e ,e0 ,. .
City/State/Zip: Sav71/44, k ,'74 - 01073 Phone.#: 9/37o/ Y --)
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 (fall and/or part-time).* have hired the sub-contractors
lis' tad on the attached sheet. 7. 0 Remodeling
2. I am a sole proprietor or partner-
These sub-contractors have. ship and have no =ployees 8. 0 Demolition
employeesand lia.ve worke rs' . s. •
working for me m any capacity. 9. 0 Building addition
_ coinp._insrrra-ncr t: .. __„_____
No workers' corarr. insurance
10.11 Electrical repairs or additions
5. 0 We are a corporation and its
3. 0 I am a homeowner doing all work officers haveLercised their .
.1 11.0 Plumbing repairs or additions •
myself. [No workers' comp. right of exemption per MGL
12 0 Roof repairs
insurance required.] f • c. 152, §1(4), and we have no
employees. No workers' 13.0 Other
comp. insurance requited.] •
... ,
Any applicant that checks box #.1 must also fill out the section belo'wshowing theirworlors' compensation policy information.
t Homeowners who submit this afftdaidt int:Heating they are doing ail want 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 tbose entities have
eanployees. XI& sub-contractors have employeeS, they must pn2vide their workers comp poRcy number.
l am an employer that & providing workers' compensation insurance for my einployees. Below is the policy and job site
information. .
.
. . •
Insurance Company Name: •
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/StafeiZip:'
Attach a copy of the workers' compensation policy declaration page (showing the policy number andexpiration date).
.
Failure to secure coverage as required inisier Section 25A. ofMGL c. 152 can lead to the imposition of minal 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
°flip to $250 00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Offibe of
Thif the DIA for insurance coverage viiifiCiTioii. _ _ ._ , , . „
[Ito heber ' --;" - ' - ' ' - aitie f that the information prOvididab _Und.C;r
_ .y_c _ n - pains , , pen s o perpay
g
Si u. . ture- ., A "..,Ir /Maar_ , • ea. - - .../ D )() .
....
Phone 4: 9/3 5" 2 -7 01 yi _ - •
,
- Official use only. Do not write in this area, tO be ciiiiiplet.ed by city or townOirwied
• City or Town: "- PermittLicense # • _ .. ,
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 Applicable ❑
Name of License Holder : 60044) / L ' '/ , y� E 2.01,4 5
License Number
I 611)404 RD So�><)� h AA 0/073 �r ZDID
4 ,
g----e---1 Add Expir tion ate
X)3 SLR 0/
S gnature Telephone
f;i t ltiislye`',, s ;-lnlbrciv me" 'br Ctaal"WASUM =- :.W 1 Iliz Not Applicable ❑
H4- co/dTk46 Rs f z973t
Company Name Registration Number
/55 O e D fLG 46 iz11y�af3
Address ,y� Expiration ate
50 � 0 6 / ''l4 0107 Telephone 7 . Z ? D 1 /v J
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 ❑
icefflom '° iO E. j� ;
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) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [L7 Siding [p] Other [0]
Brief Desc� ' tion of P oposed ,
Work: /C �Ib t XrST � . f'o�ct ��4Li' s A Ir1S74i-L Sc,e� �1�cL�ss 1
Alteration of existing bedroom Yes No Adding new bedroom Yes K No
Attached Narrative Renovating unfinished basement Yes ( V^ 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
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
44 I, A(�ull - /1(1,/JD ,-9L , as Owner of the subject
ro ert
P P Y
hereby authorize
to act on my be alf, in all m -tters relative to work authorized by this building permit application.
h /h0
Si. ature of Owner Date
+ lef)tt J Alma- , 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.
E ,ti P4 E
Print () J
Si of Owner /Agent Date
R
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 i a
Frontage .-- 5P(11 1
Setbacks Front l a r o
i
f
Side L:' t R: i L: R:'
Rear i
ALA, 5 A 0
Building Height 1'° j 1 s
Bldg. Square Footagea % 1 I/ I I
Open Space Footage % I
(Lot as g� minus bldg & f 5 ,_ p..�s ?
parking) `7�
# of Parking Spaces �?13' " 6 5 'n .__LW _.
Fill: ._.. _ ... .„ 1 , . .—_. .. �,.. �._._ ,
(volume & Location) i 11 •---i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW r6 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 E Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 52) DONT KNOW 0 YES Q
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 9)
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
IF YES, describe size, type and location: I
E. Will the construction activity disturb (clearing, grading, e 1 - vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO I9
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
ma qi.
City of Northampto
Building Department _ ::
212 Main Street s
c::, i . �toom 100 �, mo
Northampton, MA 01060
■ phone 413,581 -1240 Fax 413- 587 - 1272 _ ,-
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.1 Property
l, Add dress:
This section to be completed by - office
//7.- /vLj ~� Sr Map Lot unit:
72 o2 'VG L, r Zone Overla Des c
SIm St D CB District
SECTION 2 .PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: 0/ o&
111I�,14 -01 KE &e6��""�! r �Akl 111 D 9 76t) 12- �V CW S 7, FLo�2��c t k 4 f ,f
Name Print) Current Mailing Address:
4 / l 3 s N(� 7°7'4*
4
Telephone
ignature
2.2 Authorized Agent: Q D', 3
Dw44,D /31 41E1-- c. , 3 6_LEL)D4¢L& gJ so 07 N ffl 107 � iv ,F
Namerint) Current Mailing Address:
i i qt 3 , Z"/9 L3��
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building
eao, w (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
DD �. II) from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) /0 00 U. 4t) Check Number :0�/ k 7)
This Section For Official Use Only
Date
Building Permit Number:_ Issued:
Signature:
Building Commissioner /inspector of Buildings Date
File # BP- 2010 -1068
APPLICANT /CONTACT PERSON EDWARD P HAMEL
ADDRESS/PHONE 155 Glendale Rd SOUTHAMPTON (413) 527 -0164 0
PROPERTY LOCATION 12 NEW ST
MAP 23A PARCEL 226 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out q � O
Fee Paid .C/ 6 1P
Tvpeof Construction: REPLACE PORCH WALLS W /SCREEN /GLASS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 020695
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
Demolition Delay
. 6174
Signs of Building fficial 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.
' :121 ‘ 1 E . BP- 2010 -1068
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: renovation BUILDING PERMIT
Permit # BP- 2010 -1068
Project # JS- 2010- 001569
Est. Cost: $10000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: EDWARD P HAMEL 020695
Lot Size(sq. ft.): 9147.60 Owner: MODESTOW IAN E & MICHELLE M KERSBERGEN
Zoning: URB(100)/ Applicant: EDWARD P HAMEL
AT: 12 NEW ST
Applicant Address: Phone: Insurance:
155 Glendale Rd (413) 527 -0164 0
SOUTHAMPTONMA01073 ISSUED ON:5/27/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE PORCH WALLS W /SCREEN /GLASS
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 5/27/2010 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo