24A-175 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 hone owner exemption, ° 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/footines (before back-fill),
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.
lithe 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
•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
•,
..
. .
. . The Commonwealth opfassachusetts
,--- Department of Industria I ACciderzts • ,
I = ,....q . . 47 ........—, !I
Office of Investigationi • '
600 Witshinp,ton Street
Boston, MA 02111 . . .
- ----- •zz
, •?,,,.."-.=- i ," . , , www.mass aov/dia
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers - -
Applicant Information •
, Please Print Legiblv
Name (BusineseorganiiationandividuaD: I / •,,,le, , -.4/k, ,,
- _ Address: /Oa( Z.7e;PTAr _,? E ./.. 4 a/ew
,
,
City/State/Zip: - . Phone .# 7 ' 7V)-r -
Are you an employer? Check the appropriatebox: • . •Type of project (required): 11'.
1.0 I am a employer with • 0 I am a general contractor and I
6. 0 New construction
-,...loyees (full ancVor part-time).* have hired the sub-contractors
listed on theattached sheet 7• 0 Rempdeling •
Z. ,Ti I ani a Sole proprietor or partner-
These sub-contractors have.
ship and have hp elloyees •8. 0 Demolition
emiloyee_s•:_indhave worke rs' . - . .-.. -; •
working forme in any capaaity. - 9 rj
[No workess" comp . iris-trance
rdquiril , 5. 0 We are a corpoiation and its 10.0Electtical repairs or additions
• 3. 0 I am a homeowner doing all work officers hai-e‘ethised their . 11.n Plurnbing repairs or additions .
myself [No workers' comp. • . right Of exemption per MGL 1-1 • -
12.0 Roof repairs . •
insurance rev t • • . : c. 152, § 1(4), and we have no • . , • .
, . . emp [N Wor ' 13.0 Other r
, .
POMP- inSitranCe required-1
. .
*Any applicant that checks box nmust also fill out the section belowshowing theirivocers' compensation policy infonnation;
t Homeownera who suhrtit this afftdaVit.inOcaning they are doing a/I work and then hire outside contraCtora must submit anew affidavit indicating such.
IContractors that check this box nnist attached an additional sheet showing the name of the subcontractors and state whether= notthaseentides have
eMployees. If the Mb-cootaCtorstaie paployeeS, they must provide their wOriteis7 conm. policy nmnber.
- lam an employer that & providing workers' compensation insurance for my eittplayees. Below is the policyandjob:site
information. : . . -
•
• • •
Insurance Company Name: - • .
. . . . .
Policy # or Self-ins. Lic. #: • . Expiration Date: - . - • I '
- •
Job Site Address • '• City/State/Zip:'
. Attach a copy of the workers': compensation policy declaration page'(shos!ing the policy number andexniration date).
. . .
Failure to secure coverage as reqiiire'd 'Mil* Seeticia 152 can lead to the ikiiition ofdinxiiiil iienagies of a
fine Up to S1,500.00 andfor one-year imprisonn* as well as civil penalties in the form of a STOP WOB.KOPDER. and a fine
of up to S250.00 a day against the violatOr. Be advised that a copy Of this statement may be forwarded tOtheOtrueelof
- ElesliiifibliS — oftlie Da-fo:?iiisiiialidgoiiVeiaii • _ - . . . _ _. 77=:_,..:„..,..,,_ , _ ........:„_
liTit:Wiiiii17.iiyi:77&rarns7 7 .arleijitliaithe infarnatianp);41;1.Zo ' :
_ . .
Signature: , ' - -
'
Phone #: (*/)/ . ,
.
•
. - Official use only. Do not writ' e in this area, to be completed by city or toWiiofficial
I
6.
City or Town:
Permit/License # _
Issuing Authority (circle one):
.• ' ... .
- •
.. C 1. 00 B nt ri tha ar cetr d r o e f r H so eal n: th 2. Building Department 3. City/Town Clerk Phone Electrical Inspector 5. Plumbing Inspector
. •
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction St � isor. / f � Not Appl bl ❑
Name of License Holder : /7 �G j L ' iJr r 3 -
L- e 451 "RA
License Numb e�umb,) /dtv-aL
� e
A ress � Expiration Date
C d 7- ?r''d
Signat re Telephone
;rte �ti N ot A licable ❑
11: °`e® ,te`, l3om - ''gym roA ", : e .. :� �,� A =w. ��., ��':; �- PP
Gi i.�'�I
Co nv a e
Re istration " Numb
� f 3 /)eat
Address Expiration Date
Telephone
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 buildi g permit.
Signed Affidavit Attached Yes No ❑
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 [0] Decks [[ZI Siding [0] Other [0]
Brief Description of Propose - �,
Work: CL� � >e ea/ 1 i « �aeC le(�+ 45
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a: Cf e°riir to a =ar ( i cf is n.t# eXis�il q- aiis r ci' + mpt to the fotiavIjn :
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
A) /■{ , as Owner of the subject
property i
hereby authorize Alf c t / La- 13,1-.4_ AU.A d
to act o If, in all matters relative to work authorized by is building permit application.
Signs ~ Date
✓4/ mO , 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 pena ies of perjury.
i e/c49-)e,d
Print N /^
Signature of Owner /Agen Date
3
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 ill f.,
Building Department
' Lot Size ` I 1 p
2 �
Frontage i 1
Setbacks Front
7 ; I 1 1
Sid L:= R:? ' L:1 , R:1 _.s I ,
Rear---- --
Building Height I I i 1 € . I
Bldg. Square Footage % 1 I i
Open Space Footage
Lot area minus bldg & paved
i
( g Pa d
parking)
# of Parking Spaces 1 °
Fill: l ,_..__ _....____�� �.... . �....... _. .. � m . I
(volume & Location) 1 i - i
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
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
IF YES: enter Book 1 Pager I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
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: 1
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.
ci ', of Northampton � r� � � < �� � °� �� ��
RECEIVED
,gay
Bu Iding Department d i e �a `� E
JIM
201 12 Main Street '' - $ t � of i= � � y� ��� � , � �,
Room 100 ' :.
i
DEPT OF BUILDING ! SPECTIGP Nort ampton, MA 01060 a a m ' =
NORTHAMPTON � 3 - 5:7 -1240 Fax 413- 587 -1272 m
g
x2 ` �`' ^3 %
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
-3 v5 pro sr>rec± 4( ii Map `° Lot ., Unit
/V al 1) c&g'iz9) ( .Zone ' Overlay District
�� O Elm .si District CB District _
SECTION 2, PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: 5 5 G_ 51 S'T
A i l�. SLrdlck Nye /OO2
Na - - nnt) Current Mailing Address:
,_(4(,_, Telephone
Signature -"— •�
2.2 Authorized A ent: hr /C - � L,�} � /12 /4L CA , , /� 'i
Name ' t�� %� Current Mailing Address:
.�G' v/5,5-d...7,7
��% �
Telephone ho
Signature
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
/,2. Q r o o a o (a) Building Permit Fee
1. Building /
l
2. Electrical (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) , Check Number 3f �`7 Wi P
Th Sect For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP -2011 -1035
APPLICANT /CONTACT PERSON RICHARD LABOMBARD
ADDRESS/PHONE 102 CLARK ST EASTHAMPTON (413) 527 -7427
PROPERTY LOCATION 305 PROSPECT HGTS
MAP 24A PARCEL 175 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out � /Q� *701 Fee Paid (P '(' 01
Typeof Construction: REPLACE PORCH ROOF & REPAIR PORCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 055340
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ORD TION PRESENTED:
pproved 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
�... slitle.
Signature of Building 6 fic': 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.
305 PROSPECT HGTS BP-2011-1035
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A - 175 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- 2011 -1035
Project # JS- 2011- 001672
Est. Cost: $12000.00
Fee: $72.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD LABOMBARD 055340
Lot Size(sq. ft.): 61419.60 Owner: SEIDLER ANN GANONG & JAN SEIDL RAMIREZ & WILLIAM DICKSON
BAYA
Zoning: URA(100)/ Applicant: RICHARD LABOMBARD
AT: 305 PROSPECT HGTS
Applicant Address: Phone: Insurance:
102 CLARK ST (413) 527 -7427
EASTHAMPTONMA01027 ISSUED ON:6/13/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE PORCH ROOF & REPAIR PORCH
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 6/13/2011 0:00:00 $72.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner