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_
SPECIFICATIONS FOR
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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, act as their own constructioi - 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 occupancv
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
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 me.
Date
Address of work
location
.. ,,
.. .
. .
The Commonwealth ofilfassachusetts
,-- . Department of Industrial Accidents
Office of InVestigationS . •
600 Washington Street
(-1111J Boston, 111.4 02111 . .
t:.,...:..'—'...0-
: . www.mass.gov/dia -
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
- -
Applicant Information • Please Print LeRiblv
, . , , _,
Name (BusinesS/Orgardiation/Individual): ....D avi k-e-k .uArly, 1 lC1Al
• , ; :. .
• ' Address: ql wt Lc (2 . 6P ," -
City/State/Zip: i,t)LaCec.k C4/ - (0 e.i 3 Phone:#: q ( 3
. .. "
Are you an employer? Check the appropriatebox: ' • •Type of project (required):. /
1.0 I am a employer vrith 0 I am a general contractor and I
6. 0 New consiruCtion
have hired the sub-contractors
employees (fall and/or part-time).*
listed on theattached sheet: 7. Et.B.emodeling
2 •fdl 1 ani a sole proprietor or partner-
These sub-cOntractors have .8. Q Deniilition
ship and have no employees
working for me in any caPacity. 0 w °r I c4s' - Crritildini Oil • ..
EN° workeP corn iihmliance" • 10.n B.lectrical repairs or additions
required] .- . 5. 0 We are a corporation and its
3. 0 I am a homeowner doing ill work officers Illire•f/r-erdse4 their . 11.E1 Phi:Obi repairs or additions .
myself [No workers' comp. • right ofexemption per MGL
12.0.koof repairs .
insurance required.] t ' • - . c'. 152, § 1(4), and have no - , • .
loyees [No workers' . 14:11 Other
comp insurance recrliPitd-1. ' • • - . .. .
*Any applicant -that checks box #1 must also fin out the section belowshowing their compensation policy information: ' • . '... .
l' Homeewneri who submit this afradaVitinOceding they are doingall work and then hire outside contraitora must submit anew affidavit indicating such.
:contract= that rhiP-1,- this box mustattached an addtional sheet showing the name of the snbcontractors and 'state wiether have - . •
einployees lithe sub-contractors htie employees; they must provide their wtnireis7 comp penny number.
Tam an employer that &providing workers'compensation insurance for nry einplOyees. Below & the policyandjob site
information. . . • .
" - •
lizurance Company Name: • .
. .
. .
. • . - . . . .
Policy # or Self-ins . Lic. #: • Expiration Date:
Job Site Address: : ' • • City/Stale/Zip:'
Attach a copy of the workers'" compensation policy declaration page (showing the policy number ande.apirition date).
Failure to secure coverage as retinifedniiiiiter Sectibir25A c 152 can lead to the frOPoiltibri of CriiiiMiliiiinaliies of a
fine up to 51,500.00 and/or one-year imprisonmen4 as well as cl penalties in the form Oa STOP wop4cx and a fine
" of up to 5250.00 a day against the violator Be advised 'that a copy Of this statement may be forwarded to the Oittelof ,. ,-.,,,
1
11VeklaiiiiiiSCifthe DIA
--- iiiiiis ' iiiiia ' i' '6,6iiiiieVi : ... . ' .-_- L
I elO7 hereg7rtifi un e pains penalties olperjury that infomatianprovib '
• . _ _ m
Sit,. -tare: !Li C ■ 5 " , . : 7 : . ■ ate- -:) til-•!e--- . / .?C' I t. • ,
• . . _ .
Phone 0: • q 64,-c: k(Ets .... _ .- . ._-_-. .- , , . . . - - . .
. ..._
.._
-0 use only Do not write in this area., to be conip feted by city iii tow it
. .
• City or Town:
Permit/License # _
Issuing Authority (circle one): , . ., ..
". ' ....... .
. .
6 r p . do 2. Building Department 3. City/Town Phone E #: tri cal tor 5. Plumbing bing Inspector
• -
- •
.. ,
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Constructions Supervisor: Not Applicable ❑
Name of License Holder :� ��� J `\e LS 7 02 2 a 7
n� ��AA,, A License Number
L V C \
lA C eA So Qc\ vvl A Tv -crr 1 7
• ddress Expiration Date
�:... t(3 Gtg s ; k%" 1 g'
Signature Telephone
.'= f�gfsteTeti FlottiiitmprQreltriiptiraclr '.. Uit . , t... Not Applicable ❑
�.. �. arcaigt- vac 1 4 q t C (0 o I
Company Name Registration Number
Address Expiration Date
Telephone q(3 fobs
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. e. 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 tit
ilitevrictintOWAer=emDtlen
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 El New Signs [0] Decks [p Siding [0] Other [0]
Brief Description of Proposed
Work: ��case„v�e';AA c� Seace c SO tF , l tc e1 1J C•`;��
1 11
Alteration of existing bedroom Yes ?<' No Adding new bedroom Yes x No
Attached Narrative Renovating unfinished basement -)e Yes No
Plans Attached Roll -Shee ) add. ..1 !o { vHti.LL& b 0.s.ewieK1 -
6a rl f er i ie aiir i rddai itto c tricf iu a afitejegt ij 6iffA 4:
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
, as Owner of the subject
property
hereby authorize
to act on m behalf, in all matters relative to work authorized by this building permit applicatio .
ft //
Signature of Owner Date
, 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 /1
T
Signature of Owner /Agent Date
, R K
. , ,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning rb o , t
This column to be filled in by i
Building Department d
t
Lot Size _ i ; _._ __. :_,.,. ..� _..2 . w .. _.,..t
Frontage , 1 1
Setbacks Front l ; rrn'?
Side L: R : .m.- 1 L:....___...._ R:` _
Rear
I
Building Height ? 1 f-----; i'
Bldg. Square Footage r 1 r--1 % """'"" L __.. i
Open Space Footage %
(Lot area minus bldg & paved L 1 F [
■
parking)
# of Parking Spaces 4-
Fill:
(volume & Location) t 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 NT KNOW 0 YES 0
IF YES: enter Book ! Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q ,Date Issued: :
C. Do any signs exist on the property? YES 0 NO l
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 a
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 Q NO G
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
A ,
3 1
jL . ity of Northampton s � x
:uilding Department 's - f N . ,. < 4.,
juN � 7 2U L ( 212 Main Street r � w
Room 100 „�
No hampton, MA 01060 ; ffi 4 i : '
�pLOF M:"INsPEcTi 87 - 1240 Fa 413- 587 -1272
• gT H AMPTON . . • •M
y
■
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 Property Address:
/ L Cce-s ce.� =' Map . 'Lot Unit
tvI to 1 NA p t Q c � Zone Overlay District
Elm S District
CB, District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
e.6rGv^ gii lt� /6 2 C'fec.c & .
Nam (Prin Current Mailing Address:
4/3 ; G Oi 75
i Telephone
S
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 4 '' (a) Building Permit Fee
2. Electrical J ,5 � / (b) Estimated Total Cost of
cll c L (9.4-11 s Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection 5) 3 � 5
6. Total = 1 + 2 + 3 + 4 + 5 ''t 2 . S = Check Number 1
This Section For Official Use Only
Date
Building Permit Number: issued:
Signature:
Building CommissionerAnspector of Buildings Date
GAt kb 6V t(
File # BP- 2011 -1068
N 0
APPLICANT /CONTACT PERSON DANIEL DROLLETTE �. d �� vc l G'
ADDRESS/PHONE BOX 137 WHATELY (413) 665 -4818 f t3S(A. -ATF Xt'E
BASE �T
PROPERTY LOCATION 162 CRESCENT ST tJ &V 5 2 €S1 °
MAP 24D PARCEL 289 001 ZONE URB(100) /m S s
THIS SECTION FOR OFFICIAL USE ONLY: c r . of SS ACx(
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out �0 7 , j r
Fee Paid }�
Typeof Construction: FINISH PARTIAL BASEMENT OFFICE SPACE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 072267
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO PRESENTED:
L./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
111
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.
162 CRESCENT ST BP- 2011 -1068
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 289 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 -1068
Project # JS- 2011- 001720
Est. Cost: $4225.00
Fee: PERMISSION 1S HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DANIEL DROLLETTE 072267
Lot Size(sq. ft.): 4878.72 Owner: ETLINGER DEBORAH & RUTH LEUENBERGER
Zoning: URB(1001/ Applicant: DANIEL DROLLETTE
AT: 162 CRESCENT ST
Applicant Address: Phone: Insurance:
BOX 137 (413) 665 -4818
WHATELYMA01093 ISSUED ON:6/20/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: FINISH PARTIAL BASEMENT OFFICE SPACE
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: r� ��I House # Foundation:
/' Driveway Final:
a.
Final: Final: kip /i 6 Ailif yl
Rough Frame: F (
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: 0,2 2, (( (?e )
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. 1 4•444 :6 A tio I sevioc h
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 6/20/2011 0:00:00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner