25A-161 r:
\ 7%e eanvmcvruuecria o/ 44ac/u�rve&
Office of Consumer Affairs & Business Regulation License or registration valid for individul use only
{ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to
rt _ Registration: 449288
Office of Consumer Affairs and Business Regulation
�` e 10 Park Plaza -Suite 5170
Boston, MA 02116
=_, a Expiration. 12/15/2011 Tr# 291875 u
Type: ` Individual
TIMOTHY J LUCE
TIMOTHY LUCE
122 AUDBON RD. €
LEEDS, MA 01053 Undersecretary
Not without signature
5 = Massachusetts - Department of Public Safet■
7 Board of Building„ Reu,ulations and Standards
Construction Supervisor License
License: CS 100515
Restricted to: 00
TIMOTHY LUCE
1111 r
PO BOX 14
LEEDS, MA 01053
oi,.G.— ----- ...----e. Expiration: 7/15/2012
( ulnnli.aunet Tr#: 100515
•
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 1083.4 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
jermits 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 of Massachusetts
_...—..— Department of Industrial Accidents
t ■"* te
Office of Investigations
to =,-, -1.=.• t
600 Washington Street
• -.7".,:t: = 74 Boston, MA 02111
- , www.mass crov/dia
-b
•
- Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeF,iblv
' ------- 1 J i,,
Name (Business/Organiz' atio ."..divirtd) / 111,.7
Address: IC) I c,A._ 1
'-' q
2 ,-- *Z
City/State/Zip: L4 44 Cid'i 3 Phone.#: 6 /r) 2 I
Are you an employer? Check the appropriate box: Type of project (required): l
1.0 I am a .c.loyer with 4. El I am a general contractor and I
6. 0 New construction
have hired the sub-contractors
.... oyees (full and/or part-time).*
2. I am a sole proprietor or
listed on the attached sheet 7. 0 R.emocleling
II partner--
These sub-contractors have
ship and. have no eillployees 8. 0 Demolition
working for me in any c.apacity employees and have workers' _. _ _ __
_ _ insurance.: : 9 El Building addition
[No workers' comp. insurance
10.0 Electrical repairs or additions
required] 5. 0 We are a corporation and its
3. 0 I am a homeowner doing all work officers have4xercised their
i 11.0 P1 11- repairs or additions
myself [No workers' comp. right of exemption per MGL
12.1; • . .f repairs . •
insurance required.] t c. 152, §1(4), and we have no 1--1
employees. [No workers' 13.1_1 Other
.
comp. mstrranc e required.j
*A applicant that checks •box #1 must also fill out the section below showing their workers' compatsMion policy informzttion. — .
t Homeowners who submit this affidavit indicating they are doing all work 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 those entities have
employees. If the sub-contractors have employees, they must provide their workers comp. policy number.
.Tam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: • •
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required mid& Sectiori'25A 'of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 81,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORS-0.17.DER. and a far
of up to S250.00 a day against the violator. Be advised that a copy of t.bis statement may be forwarded to the Office of ,.
liffeitions - Of the Da for insurance coverage Verificitinn. ---- - : _ ." _---- :-_,_--
_ I do herebyfierti e pains and penalties of perjury that the information provided _above_isirue_and_corre.ct._ _ ..
1
Siena e: _-- ---- ;: 7.-- -'- -- ,..-- — 13a - ... / / ‘ 3 . //
, .
Phone #:
Official use only. Do not write in this area, to be completed by city or town'official
City or Town: '. Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical 5. Plumbing Inspector
6. Other . & •
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : /cos;15
License Number
Ls4c 41A ()/e5
Addres -, Expiration Date
/ 7A ,,
Signature / Telephone
9.:Rectistet d- Home=lmprovement Contract 4 a ,,,..a. x.� _ .. Not Applicable ❑
� `� LL,., �-�-- . „ .. __..,.., /y1 if
Com an Name / Registration Number
1 6 )N /2_ - - 2L 'it
Address Expiration Date
1. S •4'U 6/6 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 building p �.
Signed Affidavit Attached Yes 0' No ❑
l r� intlt xenin n
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 El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [IJ Siding [0] Other [❑]
Brief Description of Priosed j 1 a
Work: i c'a. r G;C r, :, l L,t -� i v 1 pz ((,4 VtS�e iftW e 7
Alteration of existing bedroom Yes No �! Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa:t#�N�w�Froa�se`an� ar ai�dition,.to � "e�istina- :hauslnq�ri�ripte the`fo�to�iirrnc:
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 1- 57? 17 /2 ;/'
l4— L . 1--� E If -�-�
to act on my behalf, in all matters relative to rk authorized by this building permit application.
42171 /. •3 O
/1
Signature of Owner Date
�a- ,), 1-'%c .--- , as Owner /Authorized
Agent hereby decl a 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.
J Lv
Print Name ✓ _. — w —?
07///
Signaturr"of Dyer/ gent 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 1 I i
Frontage 1 u_i i3 --
Setbacks Front $ k € i M
Side � "L:' r-+---J ' R: _ L:' < R:'
Lmi Rear
Building Height i r
1 1 i _---a
Bldg. Square Footage 1 % "
Open Space Footage
Lot area minus bldg & paved 1 1
parking)
# of Parking Spaces ~ ~-
Fill: 1 11 1 i
(volume & Location) '£ —
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:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book ! s Page € 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 Q Obtained Q , Date Issued: ,
C. Do any signs exist on the property? YES 0 NO 0
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 Q
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
,
i:z d e ra : 0 4 off U ® s � , {,. .
City of Northampton St ® 'inn- ' , ' � '4
Building Department ' � - "° ! _&
212 Main Street -' S ,._�. - .�� , '• `�
Room 100 : ® . , 1
Northampton, MA 01060 ':
phone 413 - 587 -1240 Fax 413- 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH ON OR TWO FAMILY DW LLI G
- X42011
SECTION 1 - SITE INFORMATION
This se. ion •.' W...,
1.1 Property Address:
y Vi,:_. Map Lot Unit
i r - Zone Overlay District
Elm St District CB District '
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 O ner of Record:
j r/
f? r/r-wet_Al" 4 / ( to-7- - i/z p 4 V'e—
Name (Print) Current Mailin,Addre
-- ; , 1 0 '�/ � l , —
(-}i,;„ c/i 17 Z7 :,/L /t ,ice Telephone
Signature ✓ J/
2.2 Authorized Agent:
Name (Punt) _) Current Mailing Address:
r3 3 _ T v
Signature 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 +5) % S / y
1'` ".1-- Check Number A776 9 5 ---
Th Sect For Offic Use Only
Dat
Building Permit Number: s ues.
Signature: �� g
Building Commissioner /Inspector of Buildings Date
54 DAY AVE BP- 2011 -0858
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A - 161 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP- 2011 -0858
Project # JS- 2011- 001414
Est. Cost: $5400.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY J LUCE 100515
Lot Size(sq. ft.): 7187.40 Owner: MURRAY ANDREA M
Zoning: URB(100)/ Applicant: TIMOTHY J LUCE
AT: 54 DAY AVE
Applicant Address: Phone: Insurance:
P 0 BOX 14 (413) 387 -9800
LEEDSMA01053 ISSUED ON :4/28/2011 0 :00 :00
TO PERFORM THE FOLLOWING WORK :STRIP & SHINGLE GARAGE & FRONT PORCH
ROOF
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 4/28/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner