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✓EPF_FTMENT OF BUILD?NG INSPECTIONS ` '- r =
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iNSF�C±CR 212 Main Street • Municipal Buildin -/
Northampton, MA 01060
HOME HOME OWNLR EXEMPTION CKNnWF,RDGEMFNT
The State of Massachusetts allows the homeowner the right under 780CMZ 108.3.4 to
act as his/her construction sups -sor. 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."
1 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 backflI).
sonotube holes (before pour). a rouzh building inspection (before work is
concealed). insulation inspection (if reauired) and aJin huildina 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
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
made
•
1, 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
°� R 0 The Commonwealth ofMassachusetts
L Department of Industrial Accidents
"" ` �-- Office I_zions
- ,.,T ,� J � ce o niestiga
f
} p 600 Washington Street
t- Boston, 111.4 02111
7 k_.„ ! www.mass.goti/dia
Workers' Compensation Insurance Affidavit: Buil ders/ Corm - actors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Bzsiness/Organ:zation/Individual j :� �r Q, . NQ lcv(c - N - Nc
Address: —
O1oa'1
City /State /Zip: _ „ 1.2.1. ■ Phone :4: y \ -sa 1 -
Are you an employer? Check the appropriate box: Type of project (required): I
1.g I am a employer with u 1 - 6. ❑ New construction
employees (full and/or part- t-T -te)- 4. I a m a gene -al contractor and I
have hired the sub- contractors I
listed on the a*xached sheet_ 7. R emode mg I
n 1 a sole proprietor or partner-
1 T _ T ship and have no emplo ees These sub - contractors have g_ 0 Demolition
employees and have workers'
world for me many capacity. 9. 0 Building addition
o workers' co
( =rn. ;ns ance comp. insurance.* r' " 10. Elect ical repairs or additions
required] 5. We are a corporation and its
3. 7 I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [ o workers' comp. riit of exemption per MGL 12.E1 Roof repairs
insurance required ] t c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance 13.E Other
urance required-] -
- - --- - °fsnv applicant at ,actor pox rl1 must aso nil out me sernon oeiew snow fig their work=s' corapeasanon policy mformauon.
t Homeowners who submit this affidavit indicating they are loins all work and then hi outside contractors must submit a new amdavit indicating such.
'Contractors that check this box mustanached an additional sheet showing the name of the sub - contractors and state whether ornot those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy ntmioe<.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: \cj —
Policy # or Self-ins. Lic. #: \. Q \ 155 g'it5 Expiration Date: - a,ebs - \\
Job Site Address: ' ..,. - - \,* N. 'li41..:1. ► \i City,'State!Zip:� (5,\(...0
Attach a copy of the workers' co .t`• nation 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 per<P hies of a
fine up to S1,500.00 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
Investigations of the DIA for im manse coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
- Signature=_ _I iti ;4C�� •�dI WI". Date: \\, -. \O
Phone #: - '
Offu fat use only. .Do not write to thus area, to be completed by city or town offic
City or Town: - P--er-mit/Licease
Issuing Authority (circle on):
1. Board of Health 2. Building Department 3. CityiTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone _:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Not Applicable ❑
Name of License Holder : VMVVN C . \- \1
License Number
Addr. Expiration Date
1200 - a
•. nature Telephone
9. Registered Home Improvement Contractor Not Applicable ❑
�►.r N� - sue �b-��,y�
Company Name Registration Number
5 \oar
Address Expiration Date
Telephonea\ -%'s
—
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 `> I No ❑
11. Home Owner Exemption
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 -vear 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
Y •
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House n Addition ❑ Replacement Windows Alteration(s) 1 Roofing El
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [0] Other [0]
Brief Description of Propo d
Work: CQS`c�y� b\ UicC�.I \'n�3 \i\"C`�RVJ VOLC11''t .i .3 \'C\N % � �r`3��iJ 5.`Rx
Alteration of existing bedroom Yes \/ No Adding new bedroom Yes •/ / No
Attached Narrative Renovating unfinished basement Yes N No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
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
I, \ J , as Owner of the subject
property �
hereby authorize '} } _ y\� Ne
. l 1, itTh e.,�b\\"'N>..C.--NCIl1Z\
to act on my half, in all m. er lati - o wworrk authorized by this building permit application.
Signature of Owner Date - a —
1. \S)1e.YWN �, N6cc. , 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 , ame illi
41.1 - i1 0 \\- -c
S .nature of Owner /Agent 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:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
. narking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO O DONT KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT 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 Q 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 Q NO IN
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 g
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grariing, excavation, or filling) over 1 acre or is it part of a con n plan
that will disturb over 1 acre? YES Q NO 00
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
r '
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/ Driveway Permit
212 Main Street Sewer /SepticAvailability
2„;;3 Room 100 WaterANell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413 - 587 -1240 Fax 413 -587 -1272 Plot/SitePlans
Other Specify
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
\5 1 \a A , Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: •
Name (Prin t - y' tea
�' Iv % Telephone
Signature
2.2 Authorized Agent:
w
•
Name (Print)) Current Mailing Address:
Signat - Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building • (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
___ 6. _Total =�1 + 2 + 3 + 4 +51_ _ Check Number /5J
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector ofBuiTdings Date
File # BP- 2011 -0418 "
APPLICANT /CONTACT PERSON KEVIN NETTO CONSTRUCTION INC
ADDRESS/PHONE 90 Southampton Rd. WESTHAMPTON (413) 527 -3168
PROPERTY LOCATION 15 COOLIDGE AVE
MAP 25A PARCEL 083 001 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 ,
Fee Paid % (fL39
Typeof Construction: REMODEL BATHROOM /e6",./bet) e/t c !e 27,v s cf (q Q! a N t N �/
New Construction �� S S��L �� Reez
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 1317
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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
Demolition Delay
,..,../ ,, ,,/e .- -f.,-" - F --- // //
Signature of Building Offici 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.
1 4vet BP- 2011 -0418
GIS #: COMMONWEALTH OF MASSACHUSETTS
bitapiitoeki 5 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- 2011 -0418
Project # JS- 2011- 000687
Est. Cost: $4395.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KEVIN NETTO CONSTRUCTION INC 1317
Lot Size(sq. ft.): 12501.72 Owner: NETTO MICHAEL J & LINDA L
Zoning: URB(100)/ Applicant: KEVIN NETTO CONSTRUCTION INC
AT: 15 COOLIDGE AVE
Applicant Address: Phone: Insurance:
90 Southampton Rd. (413) 527 -3168 Workers
Compensation
WESTHAMPTONMA01027 ISSUED ON:11/4/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL BATHROOM - MISSING AIR BARRIER
OR INSULATION IN AREA DISTURBED MUST BE CORRECTED
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 11/4/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck— Building Commissioner