05-056 City of Northampton
Massachusetts ' 44.W
tgl off
01/a
DEPARTMENT OF BUILDING INSPECTIONS
> a 212 Main Street • Municipal Building ;
Northampton, MA 01060 6 "^ S
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 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 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 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
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
1 The Commonwealth of Massachusetts •
Department of Industrial Accidents
Office of Investigations '
w 600 Washington Street .
r
9, Boston, MA 02111
fir: ' ` www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
`
,v
Name (Business /Organization/Individual): `.S L l i '" 4 c - ' ` 4 t.A. (4..C-1 %F t ��J i i- ��5 _
Address: . 2 Luai j .
City /State /Z /1)3.1.,iti9vs torti.J H. (} ( Q(26 Phone #: '1 13 7 (- "i9(0 5
Are you an employer? Check the appropriate box: Type of project (required):
1. 2 I am a employer with 1 4. ❑ I am a general contractor and I
employees (full and/or part- time). * have hired the sub - contractors 6. ID New construction
listed on the attached sheet. 7. ❑ Remodeling
2. [1] I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. El Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ® Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. ❑ 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.
I 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. �.r
Insurance Company Name: PEE. ft r2. (.. fiL.c 4-/V
Policy # or Self -ins. Lic. #: W C._ d S M 3 1 i) Expiration Date: 'f/ / ),
Job Site Address: 3') A f 0 LI g 4' N R3 . City /State /Zip: A <MA riPi v e 106 U
Attach a copy of the workers' compensation 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 penalties of a
fine up to $1,500.00 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 insurance coverage verification.
I do hereby certi t undephe pains and penalties of perjury that the information provided above is true and correct.
Signature: G' " " l 4 Da te: 1 /" / .t,
j
Phone #: '1 13 -- 5 q2' a lt)
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 Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
.APP /30 /2C12 /MON 02,11 PH FAX No, P. 0101 /0OI
ACORD TM CERTIFICATE OF LIABILITY INSURANCE DATE(MM;DOMM)-1
04/302012
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTTUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER.
IMPORTANT; If the certificate holder Is an ADDITIONAL INSURED, the policyies) must be endorsed. If SUBROGATION iS WAIVED, subject to
the terms anc conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER '•
NAME:
Webber & Grinnell Ins. Agency, .Inc. PHONE 413 FA 413 586 6481
MAIL' Ext r (Ar. No):
8 North King Street E ADDRESS:
Northampton, MA 01060 PRODUCER 00020678
CUSTOMER ID /:
INSURER(3) AFFORDING COVERAGE NA!C a i
INSURED ,NSLIRERA: Peerl Indetmnity 118333 j
Leonard Buck & David Fortier INSURER e: Excelsior /Peerless 111045 i
DEA: Buck Brothers Concrete Service INS.MRC: Peerless Insurance
I PO Box 416 INSURER D: ! 1
1 Hadley, MA 01035 INSURERE:
INSURER F : -- t - - --
COVERAGES CERTIFICATE NUMBER: EXP 2012 REVISION NUMBER;
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, I
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ I
ILTR IADDL
TYPE INSURANCE ISUBR POLICY EFF UNDULY aXP
,NSR,YWD 1 POLICY NUMBER (MAMDDf YY) (MMlDDryYYY) LIMITS ---1 GENERAL LIABILITY I CBP8501791 09/0512011 09/05/2012 EACH OCCURRENCE I $ 1,000,000
X COWER: AL !SE( PAL LIABIL ITS'
DAMAGE TO RENTED 1 ,
r
PREMISES (a xcurrence; $ 100, O00
CLAIt�15 - "dAPE �X 6C� UR MED EXP (Any one Far =en) $ 15, 0001,
A f I _ PERSONAL & ADV !N.UR, $ 1,000,00
GENERAL xGCRECaT_ $ 2,000,000
SENL- AGGRE SATE LIMIT APPLIES P =R I $ 2,000,000
I PRODUCTS - %CMP'O' AGC $
1 POLIC" — I FECT I L C'C' $ I
AUTOMOBILE LIABILITY 8A8528085 10/08/2011 10108/2012 CCME!NED SINGLE LIMIT
(Ea acc!dant! I $' 1,000,00 0
l 1--j ANY AJTC ALL C'✓s'PC ALTOS I BCGILY INJURY (Par person, $
j 1
1 ECCILY INJURY (Par accic!art) I $
B I X 11 SCHEDULE: AUTOS PROPER - `i DAMAGE
,
EX HIRED AUTOS 1 (Per acatlen:) $
X NON- OWNED AUTOS
i $
UMBRELLA LIAB EACH OCCURRENCE $
EXCESS LAB 1 I CLAIMS -MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
1 WORKERS COMPENSATION K850399109/0512011 09105/2012 �, ORYLIM�S I I
AND EMPLOYERS' LIABILI Y `UN
C I -N'( PROPRIETORIPAFT ER/ , -. HTIV'E 7 E.L. EACH ACCIDENT $ 100,0001
OFFICER /MEMBER En.CLLCEC N/A
I (Mendatory lr NH) E L DISEASE EAEMFLc vEEI $ 100, 0001
P ' E - leecrlt,s under I
DESCRIP TION OF CPE 2A - IONS aelr4 1 E L DISEASE - POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES (Attach ACORD 101, Additional Remarks Schedule,, If more space Is required)
1
CERTIFICATE HOLDER CANCELLATION
1FAX: 413.586.8965
SHOLLD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Northampton
City Hall AUTHORIZED REPRESENTATIVE 11..t.. re
Main Street
Northampton, MA 01060 _Barbara Grynkiewicz /BARBG
S 1988 -2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : !JAU 10 /I 4;7 . I ( ,'2. &S De 6) u
L /yi n Mq. LicenseNumber
l� � U � � ( i ✓ �f7 i�,avyy ), (f 1 �1 () 31/ J 1 y
Add( s Expiration Date
Signatu Telephone
9 .Registered Home Improvement Contractor, � �u�� . Not Applicable ❑
/b39.9
Company Name Registration Number
O41■"0 ;1-01 `7 Cl 1 a,
Address Exp atio Date
1-19I) iQk(
("1 / , r if�l7 t9 i � , 4i 11i (CTelephone LI tc jo(
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 1 No ❑
1 1 o i e Owner .E a iptio
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 in Addition ❑ Replacement Windows Alteration(s) ❑ Roofing liel
Or Doors 0
Accessory Bldg. El Demolition ❑ New Signs [I]] Decks [0 Siding [p] Other [O]
4 1
Brief Description of Proposed p,�
Work: ; t p OL 0 s �
i '': L : O j- F t�'<I Uvo I(- A til i1 Wt T r t 1 _9
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
a, am ar a n re° , ;� ,. ,a e .
6;1L (`te <house: or addition to . existing h 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 CONTRACTORAPPLIES FOR BUILDING PERMIT
1, L 4. 1,-- `--•J , as Owner of the subject
property l
C
hereby au •.rize ' 'e — ( N-e ,
to act on
0
'ehalf, • o'e to ork authorized by this building permit application.
Signate-of 0PAW Date O
1, ilA) -0 1 ,aca° a of /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.
° . + /L7I hR,&
Print tame
Signatur -P.f Of erlAgent Date
,.
,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
iA
Existing Proposed Required' y 'Zoning
This col to be fillechily ! .,
Building artnient " riv IA N'
Lot Size I
— 1 i
- ..._
Frontage
Setbacks Front
: 1 i
- ,
Side L: R: L:.
Rear i 1 i !
Building Height 1 ,
Bldg. Square Footage i , , , % ,
.
Open Space Footage %
(Lot area minus bldg & paved 1 ! 1
parking)
# of Parking Spaces
Fill:
(volume & Location) '
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book i
1 Page I and/or Document #1
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
0 , 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 0
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 (3 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
y
A ti� Depa&nerd use only A , : • : uilding Department 'C urs u l r ay e i � � ,,, Y .
1 r T
��y 212 Main Street Sewe /Se c A� r a �l a�r l ty� ����" ���� - � � � � ���`
Room 100 W ater V �Avatlab tY T
` k •'^ , S €"� y `� - ro ` # � E 141,E A r• - c# u -, � " a s ,
o ampton, MA 01060 T wo Se � a Str c Plan s ,,,, -
1 t. ofeui DWI f , d ,, - - :7 -1240 Fax 413- 587 -1272 P'l S e ` �� F if r .
e � ; �
Other Specify _
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.1 Pro ert Address:
This section to be completed by office
r) U V (j tV Map L ot U nit
Zone Overlay Di
' -Elm St. District " CB Di
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 of Record: 1 r
z Name ( t) Current Mailing Address: �-� 1 f Qla f �
Telephone �j CI /
Signature ` 5�yr' y �o �(
2.2 Authorized . • ent:
3 (
OA A Ld . 4 O �2. i 1 g,� /..--.,-6 U, r P,,,,- ,r rl i d GIG
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 e- r a t P ' " 4 (a) Building Permit Fee
e ,,,,,, iN ? . .`f e l I/0 U C)
2. Electrical (b) Estimated Total Cost of
'Construction from (6)
3. Plumbing Building Permit Fe
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) (+� bG� 0 C1 0 "Check Number
This Section For Offic Use On
Building Permit Number: ' Date'
�; . ._ Issued: • .
Signature:
Building Commissioner /Inspector of Buildings Date
•
372 AUDUBON RD BP- 2012 -0949
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 05 - 066 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2012 -0949
Project # JS- 2012- 001652
Est. Cost: $14000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID FORTIER 008026
Lot Size(sq. ft.): 142876.80 Owner: JUDD EDGAR R JR & CAROL A
Zoning: RR(100)/WSP(100)/WP(4)/ Applicant: DAVID FORTIER
AT: 372 AUDUBON RD
Applicant Address: Phone: Insurance:
32 Laurel St (413) 586 -8965 WC
NORTHAMPTONMA01060 ISSUED ON:5/1/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 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 5/1/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner