36-056 (3) •
59 3f rii-c 5
-6 act)
Dipartment of Public Safer)
9 Board of Buildirr Regulations and Standards
CorIstrLctior, Supervisor Lice7se
License: CS 67121
Restricted to: 00
(4111111
BRIAN C THOMPSON
38 WILLOWBROOK LANE
WESTFIELD, MA01085
Expiration: 4/30/2012
Tr: 21015 - " 41 0 4 141tiflOW
‘• c,—,pu4L(_ e>f
\
(‘
•
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
• , ' 1 - • • - '. r . • - • "S that the buildin • de • artment 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 -i-n- conjunction. to_the_huilding permitissued,_ 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.
Address of work
location
4,,
fi The Commonwealth of Massachusetts
Department of Industrial Accidents
At =1,w1=---...= _ l
'�- Office of Investigations •
1
y
'
_ 600 Washington Street
_ = g Boston, MA 02111
- , www.massgov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/IndivicTnal): ►p
Address: _ — i.41 j_- `. I .
City /State/Zip: Ail 1 ,r,' - e Phone. #: CD() CI .
Are yo employer? Check the appropriate box: Type of project (required): /
1. I am a emplo with 4.. 0 I am a general contractor and I
` r t t i ' `� have hired the sub- contractors 6. ❑ New construction
employees (full and/or parme). *
2. ❑ I ant a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have. no er loyees These sub - contractors have . 8. 0 Demolition
for me in any capacity. employees and have workers'
working Y P ty. 9 0 Building arlttition
[No workers' comp. insurance comp. insurance.*
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
g- a�verlc - -
3.0 lama -homeowner•doia officer i s -ve er- -cise . eir 11.0 Plumbing repairs or additions
-- _ __ .__
myself (No workers' comp. right of exemption per MGL 12.0 R repairs
insurance required.) t c. 152, §1(4), and we have no
employees. (No workers' 13. Other U)�H,
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.indipxing 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 is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Co Name: -. \\ t ice \ l c -
• YY�j
Policy # or Self -ins. Lic. #: ii • 5 y Expiratio Date: * ' f
, i
Job Site Address: 4 ? ,_ 1 0( ° + City /State/Zip: Q ,—`
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage 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. to advised that a copy of this statement may be forwarded to the Office of
Investisations of the • • • for insurance coverage verification.
I do herebycerti, , nder e • : • d pen % s ofperjury. the information provided _above islrue , correct _ __
L
�� r,,
Si :,.. ture
� ate•
Phone #:
Dfcial use only. Do not write vi th area; to 3e co i kted by city or town o ciot
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su rvisor: Not Applicable 0
Name of License Holder : h c / I '
License Number
Addre Expiration Date
"r- Telephone
9MRe4isteratl tfOmefirfPici4erttefit ihitiddtd ik i 4Wjiiia . r„>' Not Applicable ❑
Company Name Registration u •er
Address Expiration Date
Crk n( 6/elephone 9
—
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 ermit.
Signed Affidavit Attached Yes No ❑
3y Z 2; �i� =
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 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
o amp on r tnances; a e . • • • , , .. 0 - .
ral-Laws- Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition El Replacement Wi ws Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [CI]
Brief Description of Proposed ^ 00 Work: _ Ate 'ice w . 1 . • –
Alteration of existing bedroom Yes lo Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
s� „»�, r +' �i %i � "x�n ��'� §' �-.z fk;s zur 'x�ak
‘,..4:-**: e>«t rya i li u trrtl � fo r vf*A hlti uimij a:
a. Use of building : One Family 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
I, qty,e_rt , 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.
Iv
Signature of Owner Date
I v #:(60' , as Owner /Authorized
Agent hereby declare that e statements and information on the foregoing application are true and accurate, to the best of my knowledge
and hPiief
Signed under the . -.nd pen- : 4 f •erjury.
4 . ;i , 40
Pri 1 r F ! IL
Sign: r- o; Own '- r /Ag- t Date
,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information I
Existing Proposed Required by Zoning
• This column to be filled in by
Building Department
I (l ,
Lot Size I _... ` ______J m.
3 z
Frontage : ?
Setbacks Front 1 I I i
Side L:
r--1 R: L: R: L „_..„,
Rear „„. „ ,
Building Height l _'._._. 1 .-;-- l
Bldg. Square Footage % ! a
Open Space Footage
(Lot area minus bldg & paved .. ,� , ,_
parking)
# of Parking Spaces 1 i - • -
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:; j
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book P age ? 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: z
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
— " re any proposed cli angel o or a 1 lons o signs inten ed o thie"property ? YES Q 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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
t\. Frivmt t- tf `45
City of Northampton :44
.#1,4104
Building Department A*
212 Main Street
Room 100
s 20\ Nofthampton, MA 01060
-.:17.T:317.tigT;'
Ar " phone 43-587-1240 Fax 413-587-1272 1,744 ,4T
■
mostmae,t1C1.2.....
APFLICATIONTO C01 ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
_ -
SECTION 1 - SITE INFORMATION
' t
This section to be completed y office
1.1 Property Address:
Map Lot Unit
L-t( Zone Overlay District
Elm District CB District
SECTION 2 - PROPERTY OVVNERSHIP/AUTHORIZED AGENT
2.1 Owner of Rec :
$
/$‘' JL
Name (Print) Current Mailing Address:
i71 Telephone
Signature
2.2 Authorized • • ent:
_jar 111.
fr. I
Name (P Current ailing Address:
L4 61 73 atA33 J O/ (#1
Signature Telephone 1401
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Or*
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) Check Number f
*Act
This Section For Official se only -
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buitdings - Date
4 kta BP- 2010 -0875
GIS #: COMMONWEALTH OF MASSACHUSETTS
zN �R�
sd� sx� r 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- 2010 -0875
Project # JS- 2010 - 001297
Est. Cost: $1288.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): 12501 .72 Owner: ALHASSAN SOFIYA
Zoning: URA(100) //WSP II Applicant: HOME DEPOT AT HOME SERVICES
AT: 41 REDFORD DR
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401
Workers Compensation
WORCESTERMA01607 ISSUED ON:4/8/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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.
1464 tZtriAeL
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 4/8/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo