29-282 (2) DEPARTMENT OF EUI�1�G LAiSPECTIONS ti �9_ !:r
INSPECTOR 212 Main Street a Municipal Euilding �y
d
ye�
Northampton, MA 01060
The State of Massachusetts allows the homeowner the right under 780CIMR 108.3.4 to
act as I iS/her construction sup,: Li-,e state defines "Ilomeouwner' 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.degartment for the City of Northampton wants any person(s)who seek to
use the home Owner exemption- to act as their own construction super V'.So; 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 back-fill).
so-notube holes (before sour). a rough building inspection(before work is
conce-tled).insulation-inspection (if required) and_a-final-huildlnainsnection. 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 1he-work ran--be-inspected-
If the homeowner Hires other trades to perform work(electrical, plumbing&has) 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. y
Date
Address of work
location
The Commonwealth of Massachusetts
Department of Industrial A ccidents
-- ;� Office oflnlesti;aeons
500 �Fashington Street
Boston, _1LL,4 02111
www.mass gov/dia
Workers' Compensation Insurance Afffdati-it: Builders/Contractors/Electricians/Plumbers
ADDlicant Zuiormation Please Print Legibly
!dame(B:smess/Orzanization/Individual):
Address_
City/State/zip: Phone.,:
ire you an employer?Check the appropriate box: rope of project(required):
4. I am a general contractor and I
1.Q I am a employer with Q - 6. Q New construction
employees(Ru11 and/or part-time).* have hired the sub-contractors
Q ,- Lsted on the attached shee� 7- Q Remodeling
1 uTi a sore proprietor or partner-
ship and have no e �T These sub-contractors have T. li
Io,ees S. Q Lemo�don
f working for me nz any capacity. employees and have workers'
9. Q Building addition
�nio workers'ca; .inst.�a.�ce comp.insurance.-
r' i 0.n Elect`ical repairs or additions
rewired] 5. W e are a corporation and its L!
❑ I am a homeowner doing all work officers have exercised their l 1.Q Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.7 Roof repairs
msura nce required.]t c. 152, §1(4), and we have no
employees. [No worriers' 13.Q Other
-. -.
comp.insurance required_]
---
:=�:'aFp scan c:.er Cox:r..ztaut a:'SO II out tae section oe:ow snowing eta wor'sers'compeasation.poiicy intoIIIlatlon. -------
.omea m=who submit this affidavit inatcatin�they are doing aII woric and then hire outside contractots trust submit a new affidavit indicada£such_
*Contractors that check this box rrnm=ched an additional sheet showing the name of the sub-contractors and state Whether or not those entities have
e ttpioyees_ If the sub conaactors.have e-zrQloyces,they must provide their workers'comp.policy number.
I am an employer that is providzn,workers compensation insurance for my employees. Below is the policy and job sire
vzform,=on.
Insurance Company Name:
Policy#or Self-ins.Lic. : Expiration Date:
Job Site Address: _C y;Stn e/Zip:
:attach a cony of the worriers' 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
nee rip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fnne
of up to 5250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investisadons of the DLk for insurance coverage veri-canon
I hereby certify under the pains and penalties of perjury that the tnformarion provided above is true and correct
Sisnafure
Phone=:
OzTlciai use only. LJo not wrrte in this area,to be compLeied by ciry or town officiaL
City or Town:
Issuing Authority (circle one):
1.Board of Health Z_Building Department 3. City/Town Clerk 4.Electrical Inspector 3.Plumbing faMector
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 ❑
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. -Howe 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 Derson 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
� h
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing F7
Or Doors I]
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding(0] Other[[ ]
of Description of Proposed
Work: \2 X Zn
Alteration of existing bedroom Yes ✓o 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 housinc,-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 I City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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
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 pains and penalties of perjury.
P e
Signature of Owner/Agent Date
� f
Section 4. ZONING Alt 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
Duilding IIcight _
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
oarkinsl -
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 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 Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 Date Issued:
C. Do any signs exist on the property? YES NO 0
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. 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 NO U
IF YES, then a Northampton Storm Water MamagementPermit from the DPW is required.
Department use only .
City of Northampton Status of Perm&
v
Building Department Curb Cu`ttDriveway Permit
212 Main Street Sewer/Septic Availability"
ROOM 100 Water/Well"Availability {,
-� Northa pton, MA 01060 Two Sets of Structural Plans
phonp.411587240 Fax 413-587-1272 Plot/Site Plans
��--' Other Specify
AOPLICATIOW-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:
Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
14 vwner of Record:
Name(Print) Current Mailing Address:
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 ermit 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
6. Total= (1 +2+3+4+5) Check Number
This Section For Official Use Only
--Date
Building Permit Number: Issued:
Signature:
Building.Commissioner/Inspector 6f 9urdings Date
t
' File#BP-2008-0462
APPLICANT/CONTACT PERSON RAMSDEN RICHARD A&DIANA D
ADDRESS/PHONE 375 BROOKSIDE CIR FLORENCE (413)585-5970 Q
PROPERTY LOCATION 375 BROOKSIDE CIR
MAP 29 PARCEL 282 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinj4 Permit Filled out
Fee Paid
Typeof Construction: ERECT 12 X 26 TEMPORARY GARAGE STORAGE(NOT TO EXCEED 6 MONTHS)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN 00RMATION PRESENTED:
�f/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 Comrriission 'Permit DPW Storm Water Management
1/3 1 67
Signature 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&Development for more information.
BP-2008-0462
rg
GS#: 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-2008-0462
Project# JS-2008-000676
Est.Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Homeowner as Contractor
Lot Size(sq. ft.): 18033.84 Owner: RAMSDEN RICHARD A&DIANA D
Zoning: URA Applicant: RAMSDEN RICHARD A & DIANA D
AT. 375 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
375 BROOKSIDE CIR (413) 585-5970 O
FLORENCEMA01062 ISSUED ON.1013112007 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 12 X 20 TEMPORARY GARAGE
STORAGE (NOT TO EXCEED 6 MONTHS)
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 10/31/2007 0:00:00 $25.004850
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo