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1
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 afNorthampton 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 in pection pioc ssrequires 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
------ per-mits_in-conjunction.to-the_build p ermitissued,_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 pro er permits and inspections are
made
understand the above.
(Home owner/resident's • ature requesting exemption)
I will call to schedule a equired building inspections necessary for the building permit
issued to me.
Address of work
location
ti
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Office of Investigations
C. __
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ` Please Print Legibly
Name (Business/Organization/Individual): NiCS. l-1\'a1 • (\ijCiV �.%a� li 14 tkfleti5 1\`+t.z
Address: Ti3A --ices Uf
—
City/State/Zip: \vit¢ ,1101 (11.1"40 Phone#: 411.- .-.. 6W1
Are you an employer? Check the appropriate box: ,of project(required): / I
1.❑ I am a employer with
4. I am a general contractor and I 6. X1 New construction
employees(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet 7. fl Remodeling
2-❑ I am a sole proprietor or partner
shin and have.no.Ple;rees These sub-contractors have g. Demolition
employees
nd" ae workers'
working for me in any capacity.
t 9. ❑BuLlciing addition
[No workers' comp.insurance camp .nsur nre.
re hired 5. We are a corporation and its 10.0 Electrical repairs or additions
q ]
3.11 I am a homeo-wnerdoin�all work officers have txeLC eu hhe- —�1.-g plumbing repairs or additions
myself[No workers'comp. right of exemption per MGL 12.[i Roof repairs
insurance required_] t c. 152, §1(4),and we have no
employees. [No workers' i3.[]Other _
cone.insurance required_}
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation 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
iContractors 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 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$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. )5e advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereb 'certifi7 it der the pairs and pennlrips of perjury that the information provided above ts.true anil_correc
{{
Signature: s, L- 0�, Date; p (g 3-Phone#: c'1%,
Al. ,-lac- LctTY
Official use only_ Do not write is area,to be completed by city or town offciaL
City or Town: Permit/License#
Issuing Authority(circle one):
I:Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector_
6. Other
Contact Person: Phone#:
or
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ID
% '�
Name of License Holder: t ic% t (-
yf ' 0/1 1‘
)1 License Number
i'.:10'4 k� x a,
141 \lit 01-440 4-1i L'
Addre k Expiration Date
4 Ay.,,v1.5i-.141
Signature Telephone
9.Registered Home ImprnvementContraotor k, ; '. ,0;4, , ._..,. Not Applicable ❑
. 'V\INAc. Z..f114AI ‘Icli P4 p5-64:1 54-ettn kl\la/
Company Name 1 Registration Number
`
„., IA gb 14
' Address Expiration ate
?n1'» A i 5th _Telephone`kt/472',5--LPII
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 )4 No...... ❑
11. Home wrier g emp ion
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
..-- .NnrtttarriPti7n`C?rdiriatice&ile-andsLorat°22orriag-L/aw-s dnd-S . - • -, . usettsGeneral-L-aws-Annotated.:
Homeowner Signature
ti
y
•
a
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ( I Addition n Replacement Windows Alteration(s) in Roofing
Or Doors
Accessory Bldg. I I Demolition New Signs [D] Decks [[J Siding ; Other[D]
Brief Descri.tion of Proposed t ' ` r
Work: -:-- , ._ _ whir' M.M. t 4 ii >c ' ' wi)t. �:w t4- X.
Alteration of existing bedroom Yes o Adding new bedroom Yes +✓ No
Attached Narrative Renovating unfinished basement Yes Pe'"
Plans Attached Roll -Sheet
6a tf Neviihouse"a"r1et._or.:additlorfto`exittna housing, a it�(ete=#fie foltowin :
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, _ L Q "TGl _tf , as Owner of the subject
property
hereby thorize A c' V"`v
to act o my b7tt, iyatl- tters relative to work authorized by this building permit appii ation.
/
Signature of Owner. Date
I, N \-'PA as Qvri4c4Authorized
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 pains and penalties of perjury.
14 fya< tifitt
Print Name
_- b tl --
Signature of Owner/Agent Date
4
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 7
Side L. -__.__.__ R...____ L:1 __. R'______
Rear _�c
Building Height �"
Bldg. Square Footage i % r""""""
Open Space Footage _.-_.
(Lot area minus bldg&paved ,,„_,.„
parking)
#of Parking Space
Fill:
(volume&Location) _ _____
A. Has a Special Permit/Variance/Findin er been issued for/on the site?
NO 0 DONT KNOW YES
IF YES, date issued:;
IF YES: Was the permit recorded at the Regi i'y of Deeds?
NO 0 DONT KNOW YES 0 _
_uw
IF YES: enter Book } x 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 (3 NO
IF YES, describe size, type and location:
T.zt_ ` D: Are thereany proposed changes to-or ad ditions of signs_intendeaTor the property? YES 0 NO er
1. .. . .. �......�,,..,�.w.w�,.�.,,....�..__ ...��,..w.... ___.__�..-....m.�____._..._.,..._�.___
IF YES, describe size, type and location: ,
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.
. •
if,=;a3:11.1t0 fliV,,,K:.',1,1:0767,4iltite:OUWatovl:r,-,!V:,'-''-et-r---:.4Nt
,s''''''-*Nigxce's--,•"'--,-',4:1.-i,::::=7,1/1-•,‘,.00,14,-*:,,z-f-VAlea,?-, ,A'1-,51V
City of Northampton '11y.,s749,,,; icntt,,,,,,,nilitilvi,„Na;pv:4-A:1-,-) ;,,M-Nrit,:xt$t
---= , 1 Building Department-
..ifi:-.-',, -",,..,44,,,,414.4ay,
212 Main Street ,..-.0yuo, 00 -. .-yoij.i,iittY',' :,m-m.,',..,
44,,,,,,
Room 100 ,.4t,„' '/W„=„17,4,',,
AUG - 22013 , orthampton, MA 01060 ir',4,Se ;Oot,St. ',''a artsrAt ri.,...,:-.., ?,',a,:-.41-4::,,s;,--.-'-,
pho e 4 3-587-1240 Fax 413-587-1272 Rio ' it'r Ibtie''5.-;C*.4''...1.4-if,•,*0.4,;',,,:ieis;:t.,-,,,.,,14:74,„,,:,,,,tp,z-,
:-.,?'":-.. .„.40,'"::-.7,;.,..._
DEPT.OF BUILDING INSPECTIONS
O•e4t.v‘.,',,°,:.-4,444.w.,,,,,,,,,,,...-...--,,,,,,,,, ,„,'f.'f„, -:',04.:il-Zz-,;:=4.-Te-t,-!4V:2,t4.4,304.,,,
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
, .
730 0 c C L -c( Cf- Map Lot Unit
• NO -,y-\ v\ 1 floo 010 6 0 z66 Overlay-District
EirmSt:District CB District
... ...
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Recor.
---3-0,--(_ tr
Name(P Current Mailing Addre ,-, ( el
illa
Telephone 0 6'0
Signature ."' 6/,/cf(14) 7, tik3-32-9 -077t4
2.2 Authorized Acient:
IA Aft< 144t)SL( ''il'.:E>)lc) X 't,k, cl.o.(oht, hsv, C‘534
• d s
Name(Print)-, Current Mailing Address:
' 4tv-cAIT .4.Vir—67- - tiql
Signat re Telephone
SECT N 3-ESTIMATED CONSTRUCTION COSTS
item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Buildin 9 Permit Fee
.
2. Electrical (b)Estimated Total Cost of
....,....,.
, Construction from(6)
. -
3. Plumbing . --....-/ Building Permit Fee
4. Mechanical(HVAC)
.-___...-
5. Fire Protection , t
6. Total=(1 +2+3+4+5) 1------T:t7:-W—ii.. Check Number 9• //3 I
- -' This Section FoiOffinialUse Oriry---- - ' - --
• . .
•- .
Date
Building Permit Number: Issued:
Signature:
_. ... _
Building Commissioner/Inspector ofBuildings-- -- -- •• _ . Date
1
A
File#BP-2014-0124 a
l 6 P I
APPLICANT/CONTACT PERSON MARK LANDY /j
ADDRESS/PHONE P 0 BOX 61 ASHFIELD (413)625-6999 O A- "
PROPERTY LOCATION 30 ORCHARD ST 4
MAP 25C PARCEL 167 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out /134/ �
Fee Paid i
Typeof Construction: CONSTRUCT 6 X 14 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 077431
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOFMATION PRESENTED:
',Approved 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 BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
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
- I lition Delay
Si: • e of Building Of icial 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.
M R
30 ORCHARD ST BP-2014-0124
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C- 167 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit# BP-2014-0124
Project# JS-2014-000239
Est.Cost: $5500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LAN DY 077431
Lot Size(sq. ft.): 8319.96 Owner: MARCHAND SOSHANA&LUKE JAEGER
Zoning:URB(100)/ Applicant: MARK LANDY
AT: 30 ORCHARD ST
Applicant Address: Phone: Insurance:
P 0 BOX 61 (413) 625-6999 0
ASHFIELDMA01330-0061 ISSUED ON:8/8/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 6 X 14 DECK
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 8/8/2013 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner