24D-236 (3) ' # I a:sacimsctis �'
a
,,,,n- - DEPARTMENT OF BUILDING INSPECTIONS �
INSP�CTCR 212 Main Street • Municipal Building r —
Northampton, MA 01060 \'— '�
HOME OWNER ER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as ;pis /her construction sup .- sor_ 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
d welling, 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 insnection (if reauired) and _afnaLbuilydinginspection. 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
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
•
4.fN, The Commonwealth of lIassachuse rs
T ,Department of Industrial _4 ccidents
l Office ce of Investigations
1 T� j 600 ashin� on Street
^^,-'' r' Boston, ALI 02111
j ,.:- . 15,'
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
AD D11cant Information Please Print Legibly
Name (B- siness/OrganizanonilndividuaI): WINDOW WORLD-
- - - 56 Dimock Street -
Address. Leeds, MA 01010
CIty /State/Zip: 5! ' ! • one .
Are you an employer? Check the appropriate box: Type of project (required):
4. I am a QeneraI contractor and I
1. ❑ I am a employer with ❑ 6. Q New construction .
e Ioyees (foil and/or part- time).* have
hired
the sub- contractors
r 1 listed on the =ached ghee Q R emodei
ing l i
I � am a sore proprietor or partner -
These sub - conctors have Demolition
ship and have no employ es 8. 0 Demolauon
1 working- for me in any capacity. employees and have workers' 9_ Q Building addition
[No workers' cow: a"li su ante comp. insurance.'-
required.] 5. Q e are a corpora*on and its 10.❑ Elect ica repairs or additions
3. ❑ I am a homeowner doing all work
oEcers have exercised their 1 I_Q Pltnnbins repairs or additions
myself o worn :s' caxnn. rift of exemption per MGL
12. Q Roof repair
insurance required ] t c. 152, §1(4), and we have no 13.0 Other
employees. [No workers'
comp. insurance required.]
-- ---"` iiy appucant mat C.2=1Z oox r1 angst aso IIll out me sermon oeiow snowing their wor s' compensation policy mformarion.
t Homeowners who submit this affidavit indicative they are doing all work and then bi: a outside contractors must submit a new affidavit indicating such.
Conc- actors that check this box must-ararhed an additional sheet showing the name of the sub-contractors and state whether or not those entities have
e:npioyees. If the sub - contactors, have employees, they rruLst provide their workers' comp. policy flambe
Iam 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 Se rion 25A of MGL c. 152 can Iead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a one
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.
1 do hereby ceri fy under the pains and penalties of perjury that the inforrnarion provided above is true and correct.
--- Stsuatu mss 1-.;=- - - -'� D ate: /U /6 !J 7
Pho e ' Y 7/Z- --
1 II
Official use only. Do not wrzte in this area, to be completed by cizi or town offzciaL
City or Town: Per-mit'License
Issuing Authority (circle one):
1. Board of Health 2. Building Department City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
I
Contact Person: Phone .. -:
r
WINDOW WORLD
56 Dimook St
Leeds, MA 01053
30 4...
Telephone 5884712
CONTRACT
Date tit
Thi agreertlent botween e
Chtwer)
and
f • odaftto
WINDOW '**
V lie :RLD OF LEEDS, AlASSACIIUSE S.
Pi ne
S1' li'f:"11‘14..'ATIC)NS
• e ,
.. . .
_ !lott2rs
70'i) or Olt- t1 coutx,xt
tiet
it ptr „ability io obtain
' ghol!
Afl c'ier par
Lo cr4C
2 r , ttr on the 4g!,
, t ort,iftiul) w ncut.iccur
_
, .1 CrwrIer
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor Not Applicable ❑
/4monde)
Company Name Registration Number
WINDOW WORLD ?` /a e
Address 56 Dimock Street Expi ation ate
Leeds, MA 01053
586 8712 Telephone
—
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. — Home 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 -vear 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
S
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House n Addition ❑ Replacement Wind Alteration(s) ❑ Roofing n
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [D] Other [D]
Brief Description of Proposed -_.
Work: _4- & Sr 4/4- Luc_ • cf
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
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 -- 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
I, _ `_ S ( , as Owner uthorized)
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
an`d �ielief.
Signed under the pains and penalties of perjury.
Print Mme
Signature Owner Age .o7 Dat
�
Section 4. ZONING Alt lnformation Must Be Completed. Permit Can Be Denied Due To tncomplete lnformation
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
-----'-------- - ---------'---- ----------------
Frontage ---------�---- ------ -- -- - -- '-'---- --
Setbacks Front „--- '
---
Side
Rear
Building Heigh ---- �---. ----
Bldg. Square Footage
„ ��
Open Space Footage __ m ___ __ r--
(Lot area minus bldg & paved
_nmmo�
# of Parking Spaces
�--- ---- ----
Fill: -----'-- ------��---- ----�-�-��— --����-
(volume a Location)
A. Nas a Specta[ Permit/Variance/Finding ever been issued for/on the site?
0 0 ��
NO \~� DONT KNOW \~� YES \~�
IF YES, date issued:
`-----------
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 ) DONTKNOYY 0 YE5 0
IF YES: enter Book Page � and/or Document#
------` ---- ----- '--------` -
��
B. Does the site contain a brook, body of water or wet[ands? NO \~ �� / DONT KNOW \_/ YES \� ��
�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained /�� Obtained Date
\_� ~ , Issued:
/ _�
C. Do any signs exist on the property? YES \ NO \~ /_�
�
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 WIU the construction activity disturb ring, gradingexcavation, or filling) over l acre orisKpart ofa common plan
that will disturb over 1 acre? YES ) NO (� )
�� ��
|F YES, l6en Northampton Storm Water MdnagehTehfPennit from the DPW is required
ti
Department use only
City of Northampton Status of Permit:
`, Building Department Curb Cut/Driveway Permit
212 Main Street
Sewer/Septic Availability
Room 100 Water/WeII Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 41,3 -58 1240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify
APBLtC,ATI{?N TO C RUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SEkT SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map Lot Unit
Zone Overlay District
/ i t rro 51)Ct T - _57
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
yduil 1--v � � L �.- /1 5' Iic: siiee % , <Jcv � <<, 2,
Name (Print) Current Mailing Address:
• Telephone
Signature
2.2 Authorized Agent:
�� c ►�
r— as t "c6 ad i / h9 a C./4- s ' I c t c: s1 evio -5
Name (
Current Mailing Address:
Print J � X 7, �.
S. ture Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
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
5) /CJ /�i r.hark Nnmher e 1
0 Tidal -(1 i�igi 4 This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector ofBuildmgs Date
` BP- 2008 -0430
GIS #: COMMONWEALTH OF MASSACHUSETTS
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- 2008 -0430
Project # JS- 2008 - 000634
Est. Cost: $4015.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq. ft.): 10715.76 Owner: LOVELL KRYSTYNA
Zoning: URB Applicant: John Corbett
AT: 194 PROSPECT ST
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586 -8712
LEEDSMA01053 ISSUED ON:10/23/2007 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.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 10/23/2007 0:00:00 $25.002705
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo