24C-184 • City of Northampton
Massachusetts , ,
r.z e k r`».
h ' DEPARTMENT OF BUILDING INSPECTIONS y a
212 Main Street • Municipal Building c) i3 „ . "+r
,�. Northampton, MA 01060 �s'rt'�^ °riV`
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 permit nd inspections as required can DELAY the project until such time as the proper permits
and insp ' ions are made
1, / , / 2 7f4.'/ lT / ' , understand the above.
(Home owner /resident's signatur r qu sting exemption)
1 will call to schedule all required building inspections necessary for the building permit issued to me.
Date 7- 36 -20 i ,--
Address of work location 2%7' CAE S &4 . r,
•
The Commonwealth of Massachusetts
..... Department of Industrial Accidents
t : ,, ,
Office of Investigations
600 Washington Street .
1 Boston, MA 02111
` ',4, www.mass gov /dig
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):
1.0 I am a employer with 4. n I am a general contractor and I 6. E] New construction
employees (full and/or part- time).* have hired the sub - contractors
listed on the attached sheet. 7. El Remodeling
2. n I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. n Demolition
for me in any capacity. employees and have workers'
working Y P Y 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.
"fit
I am a homeowner doing all work officers have exercised their
11.n 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
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.
I am an employer that isproviding 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.
I d ereby cer ;1 nder he . ' ins and penalties of perjury that the information provided above is true and correct.
immature: ` /(IJJ
1' a Date: 3 o• . 0
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. Bo of Health 2. Building Depart 2. City /Town Clerk 4_ Electrical Inspector 5. Plumbing Inspector
6. Other •
Contact Person: Phone #:
•
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9: Reeiistered. Home Improvement y Gon 'tractor Not Applicable
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M 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 ❑
1Ir:Iome- -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 - 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" certif -s and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State an teal Zonin Laws . d State of Massachusetts General Laws Annotated.
1,(
c / .
�( f
Homeowner Signature /f1 /y /
•
SECTION 5- DESCRIPTION .OF PROPOSED WORK (check all applicable) y
New House ❑ Addition [T Replacement Windows Alteration(s) n Roofing
Or Doors D
Accessory Bldg. ❑ Demolition I5A New Signs [t]] Decks [p Siding [El] Other [O]
Brief
Description of Proposed
Wr k: a /l
6 in D b � Z ' /r:, 4' J)
Wor
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
c�;"�"`*�""�`,. aar`,. 's�'�`"�` „��a � -� �., -� „dam s�^�r� >"^�..'"i�.^.�°�g;�t�.`�.....< � „A;�.'� �F � „� ,..,
6a_ Ch7416 rad ar a rellii i to ealiffic ,hou Tiro, iiTiiete.therICAGwi iii:
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 -=i OWNER .AUTHORIZATION '- TOrBE COMPLETED WHEN
OWNER AGENT OR.CONTRACTOR APPLIES FOR "BUILDING PERMIT
1, , as Owner of the subject
property
hereby au orize
to act o y behalf in al atters relative to work authorized by this building permit application.
wt1a - :2(i-dig a/ 7 _ 3o 2Q /,
Signature of Owner
Date
i .,i, /)
ii9f "' `"�'�".. " i� _/ /t.5G as Owner /Authorized
Agent hereby dec re that the statements and info ation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed der the pains and penalties of perjury.
A re i, t s S. f/ /,i/0u, s r
Print Na
i Sign _ Jr o. Ow /Anent Date ,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
b
Existing Proposed Required by "Toning
This column to be filled in by 44
Building Department
f
Lot Size $ /OP ' , ? _ t
Frontage -- — ---. -- --
Setbacks Front 30 ! L.3_1_2/'
Side L:= R: - L: R: 0 ' ________
t f
Rear -�-
Building Height
Bldg. Square Footage _ % __
1ag0' 1.L11_ _.� lCn __..
Open Space Footage % .- -
(Lot area minus bldg & paved i tr , '1‘.
parking)
# of Parking Spaces
Fill: t9.-
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES Q
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; I and /or Document #
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 , Date Issued:
C. Do any signs exist on the property? YES 0 NO fil
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 Op
IF YES, describe size, type and location:
E. WII 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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
'31 Depart,memt use only
., Si atu "' -�+. i ' .� +.Y.. + - '�h�5- A,.. #�'s+1 a t
City of Northampton ts of Permit: ` , Y 1. _
Building Department G urb CutlDrlvewayPermtt� 5 k,
f(� 212 Main Street : Sewer /Se„ptic.Ava l ablllty �. . r s,e - A
U �y� c- t a gt.'" � a m -.i c „ z:
�� �� ROOM 100 Water/We�! A.valf 1' -s�r� . }-�aL. rr':�
S EC ` -' :) Northampton, MA 01060 Two Sets of Str aural iPlans �
Y . F ; : :.t 1 � ° one 413 - 587 -1240 Fax 413 - 587 -1272 P l'o 1 5 to (ans ��� �� � � �
.io Other Specify.
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:
0 / ,.) Map Lot ”' ` Unit
/,,/ j9,R r fy 4 p, P rat) , 4 Zone Overlay Drstrrct
Elrn St. D
istrict' CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 ner of Record: p
J DAM/ D <. M&rn', ui S 7- 7 o C S ,�T $.
Name t) /It Current Mailin. Address: p
��� #J'G' d i �� Telephone - 0 3
Signature
2.2 Authorized Agent: GGG
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 �J 5T0 (J D /� (a)'Building'Permi
/ t Fee
2 Electrical (b) EstimatedTotal Cost of
G _ Construction from (6) `
3. Plumbing 960,- G, B uilding Permit Fee , _ , .
4. Mechanical (HVAC)
5. Fire Protection "G
( ) " P
6. Total = 1 +2 +3 +4 +5 Check Number
"This' Section For Official Use Only
' Building e rmit Number:. Date
Issued:
Signature:- , -
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0112
APPLICANT /CONTACT PERSON MALMQUIST RONALD
ADDRESS /PHONE 200 CRESCENT ST NORTHAMPTON (714) 377 -9838 0
PROPERTY LOCATION 200 CRESCENT ST
MAP 24C PARCEL 184 001 ZONE URB(54)/URA(46)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out � / (O h J
Fee Paid
Typeof Construction: REMODEL KITCHEN
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 FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
Demoliti • Delay
At ."
Signer re of Buil‘ n: Offr al 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.
200 CRESCENT ST BP- 2013 -0112
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C - 184 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2013 -0112
Project # JS- 2013- 000180
Est. Cost: $2400.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 12806.64 Owner: MALMQUIST RONALD
Zoning: URB(54)/URA(46)/ Applicant: MALMQUIST RONALD
AT: 200 CRESCENT ST
Applicant Address: Phone: Insurance:
200 CRESCENT ST (714) 377 -9838 0
NORTHAMPTONMA01060 ISSUED ON: 7/31/2012 0 :00 :00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN
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 7/31/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner