31B-156 (2) City of Northampton -
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Massachusetts
z
k DEPARTMENT OF BUILDING INSPECTIONS 1 ,?;_
�f s 212 Main Street • Municipal Building
y Northampton, MA 01060
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 /footinqs (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
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
� Office of Investigations J '
t = la 600 Washington Street w
il Boston, MA 02111
ffi ' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual):
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. n I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. ❑ N construction
listed on the attached sheet. 7. ERemodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. 0 Demolition
working for me in any capacity. employees and h$ve workers' 9. 0 Building addition
[No workers' comp. insurance omp. insurance. 10. ❑ Electrical repairs or additions
required.] 5. We are a corporation and its
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.
1 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. lithe 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:
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 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.
Ido hereby certify u!r the pains and penalties of perjury that the information provided abov is tru and correct.
Signature: , Date: j
Phone #: 2_6 --2-0
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 #:
a
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ��J Not Applicable ❑
Name of License Holder : 1-0C/ 1.S / (p d n " C 5 6/
License Number
3f f . T ( T A4, /( ,/eq" wiz /f4,.-►s /3-4.1 / / / /s //5
Address Expirat on Date
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Signatur Telephone
1 9 to tl to a ..' or e, mprovemed Contra o . ,' ex, tiVI W Not Applicable ❑
GU!/ /s T " j'Cs I.-1..4-11 /1 «G Y Z--
company Name Registration Number
Address / 77? c ' -Z-t f/ '7 ,<, 4„/4.,,,„g,„. Expiratio
n / ,
Telephone ?G 2 "-r
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 ❑ No ❑
11 ', " om Owner,a xtemptllon
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)' b ,
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition Ell New Signs [0] Decks [0 Siding [0] Other [0]
Brief Description of Proposed 7�
Work: Ca ."Pc1o'h.r L7.14 - ./5 /r vY
s le;•.
, is /lit, 6. ' 41 . 1P 'Ar% / e /V 4- <' - rc ,47.4" %
Alteration of existing bedroom Yes / No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sal euv house ncralddit orr to exi5tin4, tails ct, aompleiii hey ollowtn:q:
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 OW NER AUTHORIZATION - TO BE COMPLETED WHEN
OWNER AGENTIOR CONTRACTOR APPLIES FOR BUILDING PERMIT x
i c y �` ,(�{ - =
I, c I Si' �_v v Ll , as Owner of the subject
property
hereby authorize 4 c/ S v .� t' 6c1 i K~
to act y behalf, in all matters r lative to w•rk authorized by this building permit application.
16.1-141{ f ►
ture of Owner Date
1, v 41 ids (.,mac >r4 k , 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.
Z .I'e t S /)'( ^.., / (var - r.
Print Name N
.f- L /
Signature of �r'-r /Agent Date
•
. .,
Section 4. ZONING All Information Mustmpl%temit Can Be Denied Due To Incomplete Information
4xistin Proposed Required by Zoning
This column to be filled in by
4
Building Department
. ..,-- .
, - —
Lot Size
Frontage _ .
__ __
_
Setbacks Front ; 1 j
Side L: R: L:' i R: 1 =
Rear I I 1 - ..
Building Height ,
Bldg. Square Footage i i j
Open Space Footage %
r ---- 7
(Lot area minus bldg & paved ; 9
s 1 1 1 1 I
parking)
# of Parlcing Spaces
Fill:
(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 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 DONT KNOW 0 YES 0
e
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 Cr
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 e- ---7
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, ex , ation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO ap
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
tt �.. ; 7 : , - 0 De • artr 4 , t i
Ni al � � Al Gity of Northam ■ ton a of erm t'
Building Depart en r ®�y4y� rrxt �G
7 -z--, 212 Main Str: -t +e • I al• llty 44
, � Room 100 r � `� ° €Iib j 7 ` °
DEPT. 1NSPE•" TM a'
Northampton, MA 1 1 oRTHq� prpN01 � •
P-1(eMlir phone 413- 587 -1240 Fax 413 - 587 -127 . a ° ° f
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFOR MATION
ti � This section to be completed by office � �,0
1.1 Property Address: .k k ms tx 1,w, , : " '* � ,
* Zone - k Overla District . ,
s ,. `' tk, 7 Sys, x` y; ' � iv ,, moo t�" : w ', „ , „ , x,.,,,,r ,,?!. . „c c :
. ,„,,-,,,,, ' z ' pz a ` ' `4 . „ :. , - .�.s ' :, '+'yam '" '
a EIm St 'District CB District
SECTION 2 - PROPERTY OWNER A
2.1 Owner of Record: �L rr /J /�// /�►
0
ialilL• triet\C(Iii*‘
/1. N / 't? 130 c /7 /d
Name Print) Cu ent Mz(iling Address:
• i '1 Telephone
Signature L ..
21 Authorized Agent:
vc. , ✓ /faAe- ?Mc''sc. ,� � /-�. /7: 40A.
tai it 2� iv„/ /�lns//�.s
Name (Print) Current Mailing Address:
�'�"" - Zvi �''Z� 2 -�
Signature Telephone
SECTION 3 - • ESTIMATED CONSTRUCTION COS
Item Estimated Cost (Dollars) to be Offici Use Only .`x
completed by permit applicant
1. Building (a) Building PemtitFee
Z O e OOC>
2. Electrical
a (b) Estimated C
Z f Construction Total from ost (6) ofi
3. Plumbing Build Permit Fee
C.v
35 0 C} i Ca
4. Mechanical (HVAC)
5. Fire Protection /r�r'9
6. Total = (1 +2 +3 +4 +5) ®O Check Number
T hus Section For Off icial Use Only i f
"Date
Building Pe
e Number: Issued:
Signature: =
Building Commissionerlinspector of Buildings Date
File # BP- 2012 -0981
APPLICANT /CONTACT PERSON LOUIS MONTGOMERY
ADDRESS/PHONE PO BOX 951 WILLIAMSBURG (413) 268 -2028 0
PROPERTY LOCATION 9 TRUMBULL RD
MAP 31B PARCEL 156 001 ZONE GB(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 � 16
Tvpeof Construction: CONVERT EXISTING UNFINISHED BASEMENT TO 4TH LIVING UNIT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 013471
3 sets of Plans / Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
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
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.
9 TRUMBULL RD BP-2012-0981
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 156 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- 2012 -0981
Project # JS- 2011- 000981
Est. Cost: $26000.00
Fee: $156.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: LOUIS MONTGOMERY 013471
Lot Size(sq. ft.): 6621.12 Owner: BOOTH ERNEST T & CAROLYN A
Zoning: GB(100)/ Applicant: LOUIS MONTGOMERY
AT: 9 TRUMBULL RD
Applicant Address: Phone: Insurance:
PO BOX 951 (413) 268 -2028 ()
WILLIAMSBURGMA01096 ISSUED ON:5/16/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:CONVERT EXISTING UNFINISHED BASEMENT
TO 4TH LIVING UNIT
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 5/16/2012 0:00:00 $156.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
Bk: 10582 Pg: 71
Zoning Board of Appeals - Decision City of Northampton
Hearing No.: ZBA- 2011 -0011 Date: May 24, 2011
1, Carolyn Misch, as agent to the Zoning Board of Appeals, certify that this is a true and accurate decision made by the Zoning Board
Administrator and certify that a copy of this and all plans have been filed with the Board and the City Clerk on the date shown above.
1 certify that a copy of this decision has been malted to the Owner and Applicant
/
.4W Jii
The appeal period for residential findings granted by the Zoning Board of Appeals Zoning Administrator are thirty (30) days from the date
of the decision. All appeals are heard by the full Zoning Board of Appeals.
MAY 2 4 2011
CITY CLERKS OFFICE
NORTHAMPTON, MA 01060
June 24, 2011
I, Wendy Mazza, City Clerk of Clerk of the City of Northampton, hereby certify that the above
Decision of the Northampton Zoning Board of Appeals Zoning Administrator was filed in the
Office of the City Clerk on May 24, 2011, that thirty days have elapsed since such filing
and that no appeal has been filed in this matter.
Attest: 6/14141/ filat3CA—** City Clerk
City of Northampton
GeoTMS® 2011 Des Lauiiers Municipal Solutions, Inc.
ATTS8T ; 11,4.10 a. Oalifek
MUM I DONONUI
•
Bk: 10582 Pg: 70
Zoning Board of Appeals - Decision City of Northampton
Hearing No.: ZBA- 2011 -0011 Date: May 24, 2011
APPLICATION TYPE SUBMISSION DATE Bk: 10582Pg: 70 Page: 1 Of 2
Residential Finding 3/3012011 Recorded: 08/27/2011 10:40 AM
Applicant's Name: Owner's Name:
• NAME: NAME:
BOOTH ERNEST T & CAROLYN A BOOTH ERNEST T & CAROLYN A
ADDRESS: ADDRESS:
127 Prospect Ave 127 Prospect Ave
TOWN: STATE ZIP CODE TOWN: STATE: ZIP CODE:
NORTHAMPTON MA 01060 NORTHAMPTON MA 01060
PHONE NO.: FAXNO.: PHONE NO.: FAX •O.:
EMAIL ADDRESS: EMAIL ADDRESS:
Site Information: Surveyor's Name:
STREET NO.: SITE ZONING: COMPANY NAME: •
9 TRUMBULL RD GB(1001/
TOWN: ACTION TAKEN: ADDRESS:
NORTHAMPTON MA 01060 Grant
MAP: BLOCK LOT: MAP DATE: SECTION OF BYLAW:
31B 156 1 001 Chapt 350 -9,3 (1) (D): Pre - existing TOWN: STATE ZIP CODE:
Book Page: Nonconforming Structures or Uses May be
1467 ,428 Changed; Extended or Altered with a PHONE NO.: FAX NO.:
Finding from the Zoning Board of Appeals.
EMAL ADDRESS:
NATURE OF PROPOSED WORK •
Add 4th APARTMENT by finishing basement
HARDSHIP:
CONDITION OF APPROVAL:
FINDINGS:
The designated Zoning Administrator granted the Flnding based on the materials and graphics submitted with the application hearing. •
The Findings of the Board Administrator under Section 9.3 for reconstruction of a basement apartment were as follows:
1. The Administrator found that the change would not be substantially more detrimental to the neighborhood than the existing
nonconforming ground boor residence in the GB zone.
2. The Administrator found that the home would not extend any closer to any front, side, or rear property boundary than the current
zoning allows and that the pre - existing structure already extends.
3. The Administrator also determined that the new construction would not create any new violation of other zoning provisions and the
change would not preclude the ground floor from being converted to commercial use in the future.
COULD NOT DEROGATE BECAUSE
FILING DEADLINE 'MAILING DATE HEARING CONTINUED DATE: DECISION DRAFT BY: APPEAL DATE:
3/29/2011 4/23/2011 5/12/2011
REFERRALS IN DATE: HEARING DEADLINE DATE: HEARING CLOSE DATE: FINAL SIGNING BY: APPEAL DEADLINE:
4/16/2011 6/3/2011 4/28/2011 5/12/2011 6/23/2011
FIRSTADVERTISING DATE HEARING DATE: VOTING DATE DECISION DATE:
414/ 2011 4/28/2011 4/28/2011 5/24/2011
SECOND ADVERTISING DATE HEARING TIME: VOTING DEADLNE DECISION DEADLINE
4121/2011 4:00 PM 7/27/2011 7/27/2011
MEMBERS PRESENT: . VOTE
Sara Northrup votes to Grant
MOTION MADE BY: SECONDED BY: IVOTE COUNT: DECISION:
•Sara Northrup I 1 I App roved
MINUTES OF MEETING:
Available in the Office of Planning & Development
a
GeoTMSO2011 Des Laurier!: Municipal Solutions, Inc.
•
File # MP- 2011 - 0063
APPLICANT /CONTACT PERSON Berkshire Design Group
ADDRESS/PHONE 4 Allen Place (413) 582 -7000
PROPERTY LOCATION 9 TRUMBULL RD
MAP 31B PARCEL 156 001 ZONE GB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT � (f
Fee Paid /V
Building Permit Filled out
_Fee Paid
Typeof Construction: ZPA - 3 TO 4 APARTMENTS - FINISH BASEMENT
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
INFORMATION PRESENTED:
'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
(2 97( 2.—
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.