38A-021 (6) assac7i:sc 9 _ l�
i a _ -- 1,7; DEPP �TMEIvT OF BUILDING INSPECTIONS � �= I'
INSFECTC2 212 Main Street • Municipal EuiIdin� •
Nortth'unpton, MA 01060 —�✓
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his /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
dwelling, attached or detached structures accessory to such use and/or farm strictures. 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 horn 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 backlilI).
sonotube holes (before Dour). a rough building inspection (before work is
concealed ).. insulation inspection (if required) aud_aiinal_huidina 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 tan-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
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 s /p/be
Address of work
location 35 52&;1 lal€i.)J
tlwelkomernio a6 6o
• ` `A The Commonwealth of Massachusetts
(.7-‘ t Department oflndustrial accidents
j� -- :' Office of Investigations .
_ '; .3 600 W ashin Street
c .7-- t nr- ,r Boston, !114 02111
-
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organiz onAndiviri
Address:
City /State /Zip: Phone.:=; :
Are you an employer? Check the appropriate box: Type of project (required):
1- ❑ I am a employer with 4. ED I am a _general contractor and I
employees (foil and/or part - time).
have hired the sub- contractors 6 ❑ New co
2- 0,I - listed on the a+na ched ghee* 7. I Remode1i" I
L . � amI a sole proprietor or partner- �.,
ship and have no e 1oyees These sub - contractors have Demolition
$. ❑ Demo,i ion I
working for me in any capacity. employees and have workers'
' o workers co. Msuraance comp. insurance.:
9. ❑ B,iildins addition
L ' y 10. EleicaI repairs or additions
required_] 5. ❑ We are a corporation and its ❑
3. ❑ I am a homeowner doing all work officer have exercised their 11.0 Plumbing repairs or additions
myself jNo worker' comp. ri of exemption per 1MIGL 12. ❑ Roof repays
insurance rued) t c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance 13.0 Other
insurance required )
-- ttav policy information. ii- all their
'- Homeowners who subnvt 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 mustattached an additional sheer showing the name of the sub - contractors and scte whether ornot those entities have
employees. If the sub-contractors -have employe=, 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 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 $1500.00 and/or one -year imprisonment, as well as civil nena tries 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 DLk for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury than the Information provided above is true and correct.
_
Isnatt re Date:
Phone #:
Offriai use only. Do not wrzte 7 this area, to be completed by cut or town offzciaL
City or Town. PermitlLicense
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector
6. Other
Contact Person: Phone ,-:
i
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 ❑
Company Name Registration Number
Address Expiration Date
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 -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 _/ / —
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [ice Siding [El] Other [S]
Brief Description of Proposed
Work: IAISTh1.lIrrN cst VJpot9Tb rSC. .S it-c
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
I, , 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
"Pv.,k , 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 ins and penaltie of rjury.
Tkm >✓wkrl
Print Name
4 /Z'/08
Signature of wner /Agent Date
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
Lot Size
Frontage
Setbacks Front
Side
Rear
Building Height
Bldg. Square Footage Zen / °
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces -•
Fill:
(volume & Location) ...,..._„
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page, 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 Date Issued:
C. Do any signs exist on the property? YES 0 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
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 O NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
',City of Northampton Status ' of Permit
Building Department Curb Cut/Driveway Permit
212 Main Street
Sewer/Septic Avaitability
Dog Room 100 Water/Well Availability
Q CA � Northampton, MA 01060 Two Sets of Structurai Plans 41387 -140 Fax 413- 587 -1272 Plot/Site Plans
Other Specify
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
Map Lot Unit
ar 1R4)5'rAar o
Pl - Ve y�p`r7/4 JuPc o to G d Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
- PhM �, - MhGGr�tl�.1 VtYth �En1 3S - ? i�1ENJ E
Name (Print) Current Mailing Address:
- T 86 2 5 I
Telephone
Signature
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 by permit applicant
1. Building 2-5.°1`2. (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) ' 2 to Check Number
�3/ d
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector oTBwldings Date
•
BP- 2009 -0433
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: woodstove BUILDING PERMIT
Permit # BP- 2009 -0433
Project # JS- 2009 - 000030
Est. Cost: $2500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 7884.36 Owner: PENGELLY FRITHA
Zoning: URB(100)/ Applicant: PENGELLY FRITHA
AT: 35 RUST AVE
Applicant Address: Phone: Insurance:
35 RUST AVE
NORTHAMPTONMA01060 ISSUED ON:10/20/2008 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL WOODSTOVE IN EXISTING
FIREPLACE
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 10/20/2008 0:00:00 $25.00631
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo