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- DEPARTMENT Or BUILDING iNSPEGTIONS rti —_= l--/
`r 212 Main Street • Municipal Building \`\c, ,
NSP TCP � �
Northampton, MA 01060
M ii TIOvN ,C\ K OWLEDGEMENT Ln E OWNER EX r
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 structures. A
person who constructs more than one home in a two-year period shall not be considered a I
home owner."
The building=depai--tment 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 bacIdill).
sonotube holes (before Dour). a rough building inspection (before work is
concealed).insulation_inspection (if required)and_afnaLbutldinCr 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 ran 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
,. ' The Commonwealth of Massachuserts
• G Department of Industrial Accidents
— w
14 ' '
office of lnvestig ations
( ,4'
600 Washing on Street
Boston, ALI 02111
,j
� � www.mass.a ov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/EIectricians/PIumbers
Analicant Information Please Print Lesibly
Name(Business/Organized on/Individual): `'Di- 1 4-a. J,�intcrvt(,
Address: 6) nisi\A) i-
C i t y/S t a t e/Z i p / 1``J ,,.)v„l-L t- /wA. 0 10 Phone.l: 2 G 3 '. 3 2)
Are you an employer?Check the appropriate box Type of project(required):
4. am a general contractor and I I
1.❑ I p a employer with 6. pe New construction
employees(full and/or part-time).* have hired the sub-contractors
2. I a a sole proprietor or partner-
These on the attached sheet i 7. ❑Remodel
I ship and have no en loy ees These sit-contractors have 8_ JEl Demoliilon
Iworicing for me in any capacity. employees and have workers'
[No workers' comp. ;T,�„-ice_+ 9. []BuiirP addition ■
required_] 5. We are a corporation and its 10_❑Electrical repairs or additions
officers have exercised their
3.111 I am a homeowner doing all work 11.❑Plumbing repairs or additions
myself [No workers' camp_ rift of exemption per MGL 12. Roof repairs
insurance rued]t c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
Kriv applicant that caeca not r1 must aso nil out me soon below snowing their workers'cornpensanon policy information
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 m ss ararhed 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'corm.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: et d f---,i
Policy#or Self-ins. Lic. #: Expiration Date:
Job Sire 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
In vesti_ations of the DLA for insurance coverage verification_
I do hereby ce I un,er e pains and penalties of perjury that the information provided above is true and correct
---Sisnaf rep —Afai - --- Date: 1 2 ' d (.`
Phone#: G S--- ?
f „
VJncial use once_ 1)0 not riTrte tit this arcs, to be complete:by city or Town ofcial
P--ermit/License r
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.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.Registered Home Improvement Contractor Not Applicable ❑
3-4-1 C ulflAr S\-Ou /p 1(7
Company Nalme Registration Number
�!'l tea:•► S+
/-14-/c\c c r 411 Lit 6; U ' eft--2 5 -OS'
Address ? Expiration Date
Telephone,2 l,� 75) 1
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 Ofcial,that he/she shall he
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
I
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Ei Addition El Replacemen Windows Alteration(s) n Roofing n
Or Doors
Accessory Bldg. IT Demolition IT New Signs [0] Decks [El Siding [O] Other[❑]
Brief Description of Propos d r
Work: /A S+a(C IZ I�{t 1r•.a ci t '4,tJ. J
Alteration of existing bedroom Yes 1/1.10 Adding new bedroom Yes o
Attached Narrative Renovating unfinished basement Yes 1_,,-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, 111;14,e, i tA j 1,,K. AI , as Owner of the subject
property (�
hereby authorize 3e4t,e� \..tta
0- ...1s -01
to act o my behalf, in 4tg(s relative to work authorized by this building permit application.
, ` '', -�
Signature of Owner Date J/MI)
1, 3d Li L-2aci..,s' , as Owner/Authorized
Agent hereby eclare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and pen !ties of perjury.
:re.F. • e ,,-y 1
Print Na e
Pril
Sign filr'f 0 er/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 L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
narking) I i
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW Q YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0' DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained iQ Obtained Q 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 Q NO 0
IF YES, describe size, type and location:
E. Will the corstrtic.tinn 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 Q NO
IF YES,then a Northampton Storm Water ManagerrenfPermit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Gut/Driveway Permit
212 Main Street Sewer/Septic Availability
ry(l
R, Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 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
` Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
I i
2.1 Owner of Record:
in Kt— -1 4 V"4 i `I kki
Name(Print) Current Mailing Address:
' ���
Telephone
hone
Signature
2.2 Authorized Agent:
Name I�� Current Mailing Address:
Signat e r Telephone
SEC ION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
im/ v
1. Building (a) Building Permit Fee
3to
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) er, Check Number itf 3 ?-5—
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector ofKildmgs Date
#.; BP-2008-0656
GIS #: COMMONWEALTH OF MASSACHUSETTS
�'YF 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-2008-0656
Proiect# JS-2008-001002
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Jeffrey Cranston 101176
Lot Size(sq. ft.): 11412.72 Owner: PUSHKIN MICHAEL A
Zoning: URB Applicant: Jeffrey Cranston
AT: 12 BURTS PIT RD
Applicant Address: Phone: Insurance:
P 0 Box 307 (413) 268-3504
WILLIAMSBURGMA01096 ISSUED ON:1/23/2008 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 1/23/2008 0:00:00 $25.001863
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo