32C-156 I/ I I 11
l'\,1
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
108.3.4 to
The State of Massachusetts allows the homeowner the righ t under 780CMR
u persons)
act as his/her construction supervisor. The state defines " gome0wner'
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 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
p ermits 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
Date
Address of work
location
The Commonwealth of Massachusetts
Department of Indus Accidents
....*VINM
...":"7 14111:07
tgr. Office of Investigations
600 Washington Street
Boston, kL4 02111
-Work v.mass.gov/fja
Compensation Insurance LVdaV:SB-g:i1V/ddia
ere COntractors/Electn
Watts/Plumbers
A licant Information
Name biv - P1 e Print L • '
(Busuiess/Organization/ludiviciva1): (-(1/Wd ,op, e
>7
c1tY/8tate/ZiPi:C77-"Lte74 (114 Phone.#: 37 - 7 T 7 V•
Are You an emP oyer? Ch th
?lye.,r e appropriate box:
_ el • T • r
nuul 4.
s (full ti•Lui ad/Or D
2so El I am a general contractor aiul ' YPe 41.- G ( jj"
lO y ee nart-time).* have hired the sub-contractors 6. 0 New constructio
e n
. • -
am a proprietor or partner- listed on the attached sheet 7. 0 R.eroodelin5;-
ship Gild haver) eR)loyees These sub-contractors have
8. 0 Demolidon
working for me in any capacity employees and haVe WOrkatte Buildin g a
No workers' comp. insurance
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. 0 1 am a homeowner doirtg all work officers havexercised their .
11.0 Plumbing repairs or additions
myself [No workers' crimp. next of exemption per MGL .1%
12.0 R oof
repairs .
insurance required.] t §1(4), and we have ILO
employees. [No workers' 11 other
comp. insurance required.]
Any applicant that checks box #1 must also fill out the section below showing theirworkers' compensation policy infonnation. . .
t Homeowners who submit this affidivit incficating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contract= that check this' box must attached an additional sheet showing the IIZZI7C of the sub-contractors and state whether or not those entities have
employees. If the sub-ccattractors have employees, they must provide their workers' comp. policy number.
fam an employer that isprovidfrxg workers' compensation insurance for my employees. Below is the policy andjob sfr e
information.
Insurance Company Name:
•
Policy # or Self-ins. Lic. #: Expiration Date: -
Job Site Address: City/Statt/Zip:* • -
Attach a copy of the workers' compensation policy declaration page (showing the policy wither and expiration date).
Failure to secure coverage as required Udder Secti6i125A 'oftVIGT.. c. 152 din lead the imposition of criminal Penalties cif a
fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the forin of a STOP WORK-ORDER and a fine
of up to $250 00 a day against the violator. Be advised that a copyedits' statement may be forwarded to the Office of
- Of the DIA. for insurance coveraie verj.ficafion.
_ I do herebyce_ u th 1, anpenuJne.v olperjmy that the ittformationprovidedab,
Signature: ' 7 • - Date: 1 '
Phone
6 A . •
official use only Do not write in this area, to be completed by city or town offic.iaL
•
City or Town: '• Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
r
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction S rvisor: Not Applicable ❑
Name of License Holder . u' id#1./s-
�Z 53 90
License Nymberi
Add /4)/?-447/e,
Date
//' � — ( 72 - 7- 7�d?
Signature Telephone
9:;Reiq r t . rrigi itt tn+� bra "oi~ . - ,,35 a . Not Applicable ❑ �
CMg L /1,; - AC / Z c i s d ,�,-`
Company Name Registratiof , Numer
7'6 0L c� &W/( � IV/ 3/70
Address Expiration Date
Telephone 7 -7 Y
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 buildi permit.
Signed Affidavit Attached Yes No ❑
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
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
r
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition [ Replacement Windows Alteration(s) E Roofing El
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [D] Other [0]
Brief Descriptign f Proposq,d t r /
Work: t f ./ t) iii 4.- - ,7A /:r Z / 0 ( .h '` id J S /)"(. /f ,% "I / 661 / 1 /5 - C le - A 1 ,411,
Alteration of existing bedroom Yes 4,-- Adding new bedroom Yes 2 1
_Akan - elf - Narrative _ Renovating unfinished basement Yes
Plans Attached Roll - Sheet
OA T. `e? . O g att 461 atfd`ti iital sl rad t re Ir ith 116Wija:
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? i 6
i G /
d. Proposed Square footage of new construction. �� Dimensions / 0 6 X 4 J !/
e. Number of stories? / /
f. Method of heating? /7 r7'/!% ei / L Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction m/C'' ® r7(/ e XI°. i. Is construction within 100 ft. of wetlands? Yes _ 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, grc<- r :10 IL'il 5 CY , as Owner of the subject
property / authorize 1 1 J Zz4 1 d/�- e'
to act on behalf, in all matt r91atiii to work a by this building permit application.
--ems ' 0 I/ 06 ) /0
Signature of Owner Date
1, ( C /i t 49 e/'1'°f..ie✓L • as Owner /Authorized
Agen hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed er the pains and •enaltie of pe ry.
C /,:�!' 1 ,� A fr -
Print Naa i �
r ,ter ` , ,r / ' -z 7 ?
Signature of Owner /Agp- rate
& .,
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 Department a
Lot Size 1 y
Frontage
Setbacks Front = 1 I 1
Side L:= = R:l 1 L: R:`
Rear = = 1----1
Building Height t i I
Bldg. Square Footage 7 1-"-i % (-- "'
Open Space Footage % -- t
(Lot area minus bldg & paved r 1 1 i _..
parking) ,
# of Parking Spaces
Fill: ' I
(volume & Location) ,t
A. Has a Sp cial Permit /Variance /Finding ever been issued for /on the site?
NO 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 Pagel 1 and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued ,
C. Do any signs exist on the property? YES 0 NO
7
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
IF YES, describe size, type and location: 1 ,
E. Will the construction activity disturb (clearing, grading, ex vation, 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.
__ i
City of Northampton ®��� .
Building Department 4 1C 6 $*. .
0 Room 100 212 Main Street s g -
�&\ ,
A‘ - !North pton MA 01060 . s , g � r
phb ' 1 -1240 Fax 413- 587 -1272 ` � ,; ��
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
i r / �� : Map Lot Unif
N 3 I t�, T� Zone, Overlay Distract
v 0 et" �' `� c) - 11 � /� (,� 0 / O ( C� ern 5t" DlsMct CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: /
cr r t.,c- tit' 11-19 S e' --- V (� �f�(,L"'
'
Name (Print)
,----7 Current Mailing Address:
r — Telephone
Signature f R 5 6
2.2 Authorized Agent:
Al e� D � G /'1 4 q 709 6 51 6W 5//t gftV&
NatFie P t) Current Mailing Address:
d'? 7L/�7
Signature Telephone ,c3 7 l , 1 '3 d�J'� e a
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
0 �,� 'U (a) Building Permit Fee
1. Building 3 0,
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 �°
L
Th Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building commissioner /Inspector of Buildings Date
6
File # BP- 2011 -0019
APPLICANT /CONTACT PERSON RICHARD LABOMBARD
ADDRESS/PHONE 102 CLARK ST EASTHAMPTON (413) 527 -7427 aG 53 _(p f 3 9
PROPERTY LOCATION 31 KINGSLEY AVE (�
MAP 32C PARCEL 156 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out , n
Fee Paid l 5 /' •F°
Tvpeof Construction: REPLACE DECK W/MUDROOM/SCREEN PORCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 055340
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PSENTED:
Approved V 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 BO a ' 1 PERMIT REQUIRED UNDER: §
, 0 o�t1
Finding ti Special Permit_ Variance*
Received & Recorded at Registry of Deeds Proof Enclosed Tifhetram+4,404100V
Other Permits Required: 350 — i (e)
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
<.......
V
Signature of Building 0 ficial 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.
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4
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l‘ 1
i ( 14
et
,1 U
On S ic �Ct /if; 04 Additi .4r aj te ' '
Ac on ` Exist' 0r renovati oM S/ ),
Pink' C � S S O Slrttc °ns
0 p lans Incl ire --- -___._
wrier /, � - ----_.
3 sets ofp a nemeat o r Licen se p
s /Plot Plan 553 —`'_
CIE FpLLo
WING ''= j�. +i
INFO ATION p ACTION HAS BEEN T o ved RESENTED: AKENI�i THIS .PPLICAT
•
____Additional ION BASED ON
Permits rewired (see blow)
PLANNING BOARD PERMI RE QUIRED IYDER•§
Intermediate Project:
Major Project ! — Site Plan AND /fly Special Permit With Site Plan
._____site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIREb UNDER: §_
Finding Special Permit Var
Received & Recorded at Registry ofleeds 'roof Enclosed
Other Permits Required:
Curb Cut from DPW Wier Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commissin Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Sigma e 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 & Develo pment for more information.