29-391 (2) ti
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, - 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 insvected.
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
iermits 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
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. The Commonwealth ofMassachusetts
___—=___. • . Department of Industrial Aacidents . ,..• .
e, = !: ' Office of Ini . •
600 Washington Street
Boston, MA 02111
www.mass ovv/dia • • ,.
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:-...:.
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers • –
-.. ,
Applicant Information - Please Print Legibly
- ,..
:.., .
Name pusineseorpniizionfindividuaD:
. . .
- .
- • Address: ; . 7
. .
City/State/Zip: - .. . Phone.#: • - .
Are you an employer? Check the appropriatehoz: . • . .Type of project (required): I'
• 1. 0 I am a employer with 4.. 0 I am a general contractor and I
6. 0 New construction
,
have hired the sub-contractors
employees (full and/or part-time).*
2_0 I ani a sole proprietor orpartner- listed on the:attached sheet. 7. 0 Remodeling
These sub-contractors have
ship' uixl have no 3..loyees .8. 0 Demolition • . • •
working for nie m any capaeitY eglitloyees.:_iiidliave worke rs'
9: lallitlailddition
[Ne workers' comp. insiziance ' - rztrIP-intutimee-t:- . - . - .. _____....__._ .• .
required.] - • 5. 0 We are a corporation and its 10.0 Blectrical repairs or additions •
• 3. 0 I am a homeowner doing all work officers haVe‘erCised their .
. 1 11.0 Plumbing repairs or additions
myself [No workers' comp. • right of exemption per MGL
12.0 Roof repairs • . -
insurance required.] t ' . r. 152, §1(4), and We have nii •
employees. [No workers' . • 13-0 Other ' r
. ..
. . - . co nip. instuance reqUited.l. - • • • . . • • . '. -
. .
*my applicant-that checks box #1 , must also ffil out the section below showing theiriva1i cers! compensation policy informatim " ,...
t Homeowneri voile) submit this affidaVitincliciati4 they are doing all work and then hire outside contraCtorS must submita new affidavit indicating such.
:contractors that check this box anistattached an additicaaal sheet showing the name of the subcontractors and state witeliaerornotthose.eatitics have
einployees. `If the sub-contraitorshaie employees, they must providitheir wOriceis comp. po Hoy number.
I am an employer that & providing workers' compensation insurance for my einplOyees. Below is the policyand job. site
information. . • -
• - .
•
Insurance Company Name:
. • • • . . . . .
Policy # or Self-ins Lic. #: .
. . Expiration Date: - ' . .• : ,
. .
. . . .
. . •
Job Site Address: . : " . '' City/Stafr../Zip:'. - . .,• • • - .-
Attach a copy of the workers' compensation poliey declaration page (showing the policy ntrinber andreapirition date).
_
• - . . . •• . . • :
Failure to secure coverage ii reqiiiiirdinittet $66tiiiit25K'ofMGL can lead to the imposition Of 'Crating penalties of a
fine up to 51,500.00 and/or one-year imprisonment, as well as Civil penalties in the form Pf A STOP w9p4c-ORDER and a fine
of up tO S250.00 a day against die - violator. Be advised a. copy of this statement rimy be forwarded the ,.. :. • , • .
- E've — s - tia:iOii.s - TiftliDIXforirlitiance'CiVeiqrffi'aiOL .: 77 • - ' :1'...,;.; :, -, ... . ''' ,_
_ I ITO' herelyperti&aniter the p .7 i ituirl pentiltlei of:perjurythat 'infOrmationprOvi i I id:aboOilitirrejdzillibrii
/
Siti..tiiie: ''• 'Z - !..1 . ., . ' ' ith; . - 2C..) . Z . 7 . ' - . . ' ■ .
Phone it: t40/ c - .: ; . •' -...' . :. ' ' . . • ' • - - • • . . .
... •
. • ... ......----- •
. - Off use only. Do not write in this. area, to be comp • • d by city or town Official
. • ' ' ' ' • . - . .
. . •
City or Tovvn: '• Perratt/License # •
Issuing Authority (circle one): • .
.1. Beard of Health 2. Building Department 3. City/Town Clerk 4. Elecirical,Inspector 5. Plumbing Inspector
6. Other . - .
II . Contact Person: Phone #: .
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Wjpdows Alteration(s) ❑ Roofing ❑
Or Doors [�
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding [2 Other [0]
Brief Descri on Qi,ti1 osed Ai d44/5,14:/6 /1'„ ®Q `/ - 414 �J f �, � � i s
Work: p �iu,L'LL�' /vc°l���ll•`� ��� TQ �!�[�{ J GL.Q v� v tfG /,!/
/� �/� � '' _ ',Seek
Alteration of existing bedroom Yes 1/ No Adding new bedroom Yes No /
Attached Narrative Renovating unfinished basement Yes s/ No
Plans Attached Roll - Sheet
6a.. Nevdhh>,1se `olr ai cfi for o, e�c'r t�r►p . i "a s'rl p,�c tript t ' atiawllria:
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 Ta - 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 my behalf, in all matters relative to work authorized by this building permit application.
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
Signature of Owner /Agent Date
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor 4,jeen V L5' 65I I = Not Applicable ❑
Name of License Holder :1 �(�{� • T (Jd L�,
Xv..d aggi V License Number
p
Address / /, ,�/ �j�,, Expiration Date
Sig
r Telephone
9 R istere 9.H Tm Co nitra , � 4 .. .,.•i Not Applicable ❑ ,342
c7/
Company Name Registration Number
/o(/3
Address nf Expiration Date
S OL66 Telephon 5S
`ir (73
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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 .L I
on
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 1083.5.1.
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 buildine 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 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 Departnient
Lot Size i 7E I I 1 ii
Frontage .. _ _ i -, __.... i .,..� �
Setbacks Front f 1 1 I
Side L:',. R:: L _1 R:! .....
Rear .._ W., _
Building Height f 1
Bldg. Square Footage I ! FT % ' l
Open Space Footage % _
(Lot area minus bldg & paved" i
parking)
# of Parking Spaces - —
Fill: 1 ....
(volume & Location) g — --
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES 0
7
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book I 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 0 Obtained , 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 Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton ®p _ i :,� 4 `� �° -;
RECEIVED Building Department 1 = �D ' - Tt - - � � f
m ` wY "�"
212 Main Street
Room 100 � � ' F "
- 12 0 Northampton, MA 01060 ,� r
pho e 4' 3- 587 -1240 Fax 413 - 587 -1272
NORTH mart MA , , _ #
t
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: /� I
6 q ,p p I.avvG1 ,v '.� e-- Maps Lot Unit
io' ,Len c-� . 67-e' 62 Zone Overlay District
Elm St: + District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
A flitt CS 7 ea `- /0 7-i a` 6l°� a
Name (Print) Current Mailing Address:
f�' v rztlic-c' /(1" 0/0 6 2-
-� I L - e Telephone i
Signature �`7/3 > �-- - �3,
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 b ermit applicant
1. Building Oc C'� Permit Fee
(a) Building °
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) #9f O1—' Check Number / 9 (p
This Sect For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building, Commissioner /Inspector of Buildings Date
File # BP- 2011 -1014
APPLICANT /CONTACT PERSON JAMES FOLEY
ADDRESS/PHONE 10 FOREST GLEN DR FLORENCE (413) 584 -6370
PROPERTY LOCATION 69 BROOKWOOD DR
MAP 29 PARCEL 391 001 ZONE URA( 100) //WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out /39( 5$
Fee Paid /
Typeof Construction: INSTALL SIDING,REPLACE DOORS,BRICK STEPS & REPAIR ROOF OVERHANG
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
IN,YRMATION PRESENTED:
ll.• 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
//4"‘----"" 611 rr
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.
f .
69 BROOKWOOD DR BP- 2011 -1014
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 391 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Non structural interior renovations BUILDING PERMIT
Permit # BP- 2011 -1014
Project # JS- 2011- 001645
Est. Cost: $4500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES FOLEY
Lot Size(sq. ft.): 11020.68 Owner: JAMES FOLEY
Zoning: URA(100) / /WSP Applicant: JAMES FOLEY
AT: 69 BROOKWOOD DR
Applicant Address: Phone: Insurance:
10 FOREST GLEN DR (413) 584 -6370
FLORENCEMA01602 ISSUED ON: 6/9/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL SIDING,REPLACE DOORS,BRICK
STEPS & REPAIR ROOF OVERHANG
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 6/9/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner