24D-194 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
xegulations_ The inspection pracesss re that the building department be called to
inspect work at various stages, which include foundation /footings (before backfdl),
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_buildin¢� g_ ermit_issued,_ 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.
Address of work
location
.s r . - ,
The Commonwealth of Massachusetts
Department of Industrial Accidents
=7 f Office of Investigations •
t _ ® a 600 Washington Street
r J Boston, MA 02111
_� www.massgov /dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organiiati on/lndividua1): 26 5/ 4J / 06 v x -_
Address: 7 J j ai i 1
City /State /Zip: /�(i�- i4 ir�� 76A m.,& O/4 ()Phone #: 5-g6 ---- ii i ‘)
Are y an employer? Check the appropriate box: Type of project (required):
7 . I am a
1. am a employer with 2/ general contractor and I
g 6. ❑New construction
4.
employees (full and/or part-time).* have hired the sub- contractors
ti
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no en loyees These sub - contractors have. 8. 0 Dez iolon
working for me in an aci employees and have workers' 1
y ty 9. 0 Buzlcig addition
[No workers' comp. insurance comp. msuranrP.$
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 1 - - homeowner-doing-all-work o eers haveliercisea eir —1-1-0-Plurobing .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 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.
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: /J / 7 y il U T A [ ,'� 7 0 /-}
Policy # or Self-ins. Lic. #: 100 a - 3.6 38) 79 -) " 0 1 Exp iration Date: 0 5 - / Q� v
0 1
c t) �N
Job Site Address: 10 /2 ' L ) ✓ City /State/Zip 4 Id,/ a
CVO 6
Attach a copy of the workers' com ensation policy declaration page (showing the policy number and e. iration 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 and/or one -year imprisonment, as well as civil penalties is the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. 13e advised that a copy of this statement may he forwarded to the Offii:r of
Investigations of the DIA for insurance coverage verification
I do hereby: certify under the pains and penoFt►Ps of perjury that the information provided _above_is_true_and.correct_____ _ _
Si- . , ture: OMNI ,- to R ate ' I if
Phone #:e c// e-7 -7
Dfchil use only. Do not write i i this area, to be completeri ky 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 In spector 6. Other ,
Contact Person: Phone #:
AAP
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 'iLJ i &) L.) ' c) A
License Number
Addres V Expiration Date
Signature (/ Telephone 0)-(9
1:52, k.s-"g6 J1' /6
9..Regis tered ,HornellmnprovementCont - ,,. Not Applicable ❑
i e ) Si ai 1 a-7
Company Name Registration Number
Adcilrer s p / Expiration Date )
/ lE' r C��V Telephone 6-C' / ..�'(j�/ �� oz /� �" 0✓ d
I _ 0
SECTION 10- WORKERS' COMPENSATIO INSURANCE AFFIDAVIT (M.G c.152, § 25C(8))
Workers Compensation Insurance affidavi ust be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildi permit.
Signed Affidavit Attached Yes No ❑
_ _ The_currentexemption for . "homeowners " was extended to include Owner 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, ui is intended to be, a one or two family dwelling, attaohed 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 Ur tnance , a .) . - e i • _ „ w . - -# , , , • . ® .. - - # Annotated.
Homeowner Signature
s
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement W dows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding [D] Other [❑]
Brief Description of Proposed j) Y. /
Work: 7T // �' . A) l , iv o b ik
Alteration of existing bedroom Yes No Adding Aew bedroom Yes No
Attached Narrative . Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6.1f ttew tiotite nitioredcli#idr to''exiAihct hoislncil;= coinriiefe the ''.fello nneu
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 DUILDING PERMIT
I, ✓ ,,,, 4 2 4 N 1/9 l3 , as Owner of the subject
property
hereby authorize .C+ Ai ■ 1 ' 3 L T S i 4 v"
to a on m alf n a .- atters relative • •rk authorized by this building permit application.
L
/2 AO 0
'.e P re of Owner Date
I, ez) 3 .''J 1i 7 O( , as r /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.
�-4 1.0) to L 15 12,4.0 '
Print t
/ /1/0 J 0
Signature e4;t7MarIAgent / 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 . ..._ _ "_
Frontage _ _
Setbacks Front
Side L: — R:____; L :' w.____: R::_____
Rear __ __. - _W ._.
Building Height
Bldg. Square Footage ? % ---_ '_'.
Open Space Footage _,_ ...,
(Lot area minus bldg & paved
parking) �._..z
# of Parking Spaces
Fill: fl
(volume & Location) _. _
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES
~
IF YES, date issued:; "mm
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page? I and /or Document #;
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
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 0
IF YES, describe size, type and location:
`- --- – Ir "Are tTiere`any proposed changes to or additions orsigns inten ed1 t e ^property ? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb {Gearing, 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.
w.
, ., 1761,4 f -
t - m' .,0 � ���� ..0 s ,, .
City of Northampton S''„ o ,, : m
-
- Building Department curb �F �er� i `� a, ltr4
212 Main Street See ati _ __ ' ;_ , k
K �;'v' Room 100 , 4. a s ' ° r 1 4 k ;
Northampton, MA 01060 e 7 .. �.. `11 w
.
; `. ' ea s e s' ,' �,w f,i
phone 413- 87 -1240 Fax 413- 587 -1272 - �4 "t$
t om,,, x , sx «� ,,, . , ra
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
J j � M Lot Unit
/ j !� ✓ — 01 v (� (3 Zorie Overla District
Elfin St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
•
2.1 Owner of Record:
Name (Print) ,; Current ), fi re . f 0i0- N ,
/ 4 Telephone / iY�
Signatur
ze g - I4 i`P
2.2 Authorized Agent: l Ow
�,o L • .,Ai _ t4 >ro.x -> 114_9
N m (Print) r Current Mailing Adl�Yess:
Signature ( Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building fl 3). 6--1-.' (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6),
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection ,,1
6. Total (1 + 2 + 3 + 4 + 5) r ' 5 . x ,— Check Number
. This Section For Use Only
Date
Building Permit Number Issued:
Signature:
Budding Commissioner/Inspector of Date
IP . S E TST
BP- 2010 -0523
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- 2010 -0523
Project # JS- 2010 - 000737
Est. Cost: $6325.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R SIDING 026846
Lot Size(sq. ft.): 8276.40 Owner: ARSLANIAN PAUL
Zoning: URC(100)i Applicant: B & R SIDING
AT: 141 PROSPECT ST
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586 -4167 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:11/13/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 11/13/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
_______-------------_- ,,
(V
Oil7J-4-1 j
)111
9. ALL INFORMATION MUST BE COMPLETED: PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION.
This column to be filled in by
the Building Department.
Existing Proposed Required by
Zoning
Lot Size ,, 2_ 0 6 r
Frontage NIA NLA N/A
Front: l- 6 0'
Setbacks:
Side: r /
L: R: L: /OD R: / 2
Rear: V i
Height 9 /0-0-1-of
Open Space:
(Lot area minus bldg and e 70,z j f 7
Paved parking) ) C� d" v
10. Certification: 1 hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
L d'
DATE: S y � �� A PPLICANT'S SIGNATURE
NOTE: Issuance of a permit does not relieve an applicant's burden to comply with all zoning requirements
and obtain all required permits from the Conservation Commission, Department of Public Works and other
applicable permit granting authorities.
A
RECEIVE i ity of Northampton
Massachusetts
t 'L
•34 TMENT OF BUILDING INSPECTIONS fI
1", 2 Main Street • Municipal Building !f•,
Northampton, MA 01060 51 '4 A. `v
INSPECT •
ACCESSORY STRUCTURE PERMIT APPLICATION
(For freestanding structures Tess than 200 sq. ft., at (east 5 feet from any other structure)
p f (c3 Permit Fee: $25.00 Check # r 76 6
PLEASE TY PE OR PRINT ALL INFORMATION
1. Name of Applicant: pa..,ui V S 1 &V\ l �-
Address: 1 l q ! f r O S C-Ct S+ Telephone: 7 7-P / /�
2. Owner of Property: 5 4 - 1
Address: S r• V 1/4 ' 1/4 - 4-- Telephone:
3. Status of Applicant: ✓Owner Contractor
t � )(// S
4. Structure Location: A..0"-c— A..0"-c— 5 -�- /
�
Parcel ID: Zoning Map # Parcel # District(s)
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Use of Property: Single or Two Family: t/ Multifamily: Commercial:
6. Description of Proposed Structure:
One Story Shed under 200 sq. ft.: Freestanding Deck under 200 sq. ft., Tess than 30" above grade:
Other (describe):
7. Attached Plans: Sketch Plan Site Plan Plot Plan
8. Does the site contain a brook, body of water or wetlands? NO Y DON'T KNOW YES
IF YES: Has a permit been, or need to be, obtained from the Conservation Commission?
Needs to be obtained Obtained , Date issued
CONTINUED ON NEXT PAGE
File # MP- 2011 -0093
APPLICANT /CONTACT PERSON ARSLANIAN PAUL
ADDRESS/PHONE 141 PROSPECT ST (413) 727 -8443 0
PROPERTY LOCATION 141 PROSPECT ST
MAP 24D PARCEL 194 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid ''/G(P
Building Permit Filled out
Fee Paid
Tvpeof Construction: SHED 7 1/2 X 11 1/2
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOJMATION PRESENTED:
I./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
c/ZA
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 the Office of
Planning & Development for more information.