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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building 4 s,
Northanpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as l is/her construction sups:: •, sor. T he 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 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 roueh 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
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
Address of work
locationlj
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' 600 Washington Street
Boston, MA 02111
f'N www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. � I am a general contractor and I
employees(foil and/or part-time).
have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
These sub-contractors have
ship and have no employees 8. F-1 Derioliiion
working for me in any capacity. employees and have workers' 9. Building addition
[No workers' comp.insurance comp.insurance.1 g
required.] 5. (] We are a corporation and its 10.F1 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 11❑ Other
comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t 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 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Si -mature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone 4:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
M y
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
R'eats#ered'E�me'=lmoravetnen�0on�tractor� .�:;:�,_ .., .�g_ „Q -;
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 1:0-WORKERS'COMPEN'SATIOK INSUR 4NCE.AFFIQ,4,V EM G:L c.1'b2:§25'C(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...... ❑
R.�* .,
Un
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 buildine permit.
As acting Construction Supervisor your presence on the job site will be required from time to rime,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) ❑ Roofing
Or Doors D
Accessory Bldg. Demolition ❑ New Signs [0] Decks Siding (0] Other[O]
Brief DescnD1ion of Proposed
Work: ���s,1,.:�-F�_s �—(�,�C�4't3 i� \I�y
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa If:-New> ouse:and r adc�i JET,--ooexistrna Fro"�rsrnc�, co�efe��C1Ee�#attoin rn�t
a. Use of building:One Family V Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
�c
c. Is there a garage attached? (.(."�I�� .j � � �� f 1new- ry
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 V/ City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION TO BE COMPL°EYED WHEN
OWNERS-AGENT-OR`CONTRACTOR`APRLIES FOR'BUIL"DINGPERMIT
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
1, " 'l �-' , as Owner/Authorized
Ag t 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.
Ci Z/I y �f
Print N
Signature of Owner/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 /-Z7
Setbacks Front
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bIdg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Variance/Fi ndi ever been issued for/on the site?
NO \_��� VV D0N7KN0 ��� YES
����
IF YES, date issued:;
IF YES: Was the permit recorded ot the Registry ofDeeds?
NO � ) D YES
~��
IF YES: enter Book Page. and/or Document#
�� ��
B. Does the site contain abrook, body ufm/oterorwetlands? NO ��� DON7KNOVV �_� YES �~�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tubeobtained �~\ Obtained � «,� Date Issued:
v~� v_� '
C. Do any signs exist on the property? YES NO
0
IF YES, describe size, type and location:
��
D. Are there any proposed changes toor additions ofggns intended for the pnope�y? YES �~� NO_4��/
IF YES, describe size, type and location:
'
E Will the construction activity�turb(clearing,grading,excavation,m filling)over 1 acre mis it part ofacommon plan
that will disturb over 1acre? YES K ) NO
��
IF YES,then a Northampton Storm Water Management,Permit from the DPW is required.
'
Department trse onCy
City of Northampton----T_. S�fatusoPemt
�_
Building Department
0—twwvtg�
curb=Cut/D
212 Main Street Segtt�3arCIba t � t
Room 100 - afertil4IhAtraiCa[�r!>t ,
Northampton, MA 01060 F Src�ral P7arts �
=
hone 413-587 1240 Fax 413-587-1272 � �` z
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APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -S[TEJNFORMAT.ION
1.1 Property Address: Tfi�s secfion to a competed by off-rce
O'l "� Zone OveilyDistncf
i4q m a
GElrl1 St 0listncfv �- _ _ �GCB,-DLstnct
SECTION 2-PROPERTY OWNERSHIP/AUTF[ORIZED:AGENT'
2.1 Owner of Record: oo
M'<rv+-f ���Yak ILR.
Name(Print) Current
Current Mailing Address:
M `1��� k�1✓Y1v Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
S1=CTION3-ESTIMATED"CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 2 e�! �j (a)"Buirding Permit Fee
2. Electrical � � (bj Estimated:btal-Cost.of
-Construction_from.i 6
3. Plumbing ��y� Building:Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number ,
This'Section For 00161al U"se Onl
Building;Permit Number.' Date'
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
y
G escriptor/A,rea
A:FA/2Frf G
899 sgfk
B:1 Fr
11 O FP 160 sgfk
1 1 C:OFP
5 E -- '� 110 sgfk
31 D:EFP
36 vgfk
E:FU.B
10 30 sqf#
FA12Fr/B 1 1 Fes,
6 2 a �
relocated her possessions and intends to live in this structure. I do not want
to force her to move out and believe the structure makes a fine small
apartment.
We now realize this is a non-conventional and non-conforming use of this
utility building however the existing house, utility building and lot allow this
use very nicely. This is why I request this approval for a legal auxiliary
apartment.
Sincerely
Marc Etcheells
2/20/2007
Building Dept / Zoning Review
City of Northampton
RE: 411 Westhampton Road, corner of Cardinal Way and Rt. 66.
The house at 411 Westhampton Road was constructed in 1937 and a large
utility building (Dostal Dairy) was placed on the same property.
This utility building was downsized significantly (1970's?) and the
remaining structure is solid and 2-story.
We purchased the property in 1995. The former owners used it as
workshop, storage and an office upstairs. My uses were the same. Water,
power, sewage and heat were present although they have all been updated
and run from the main house underground to the utility building.
Over several years I updated this structure into a workshop and home office
layout on the 1 st floor with a living space or studio space on the 2nd floor.
Living space was never the initial intent on the 2"d floor however during the
years of renovation it evolved to closely resemble a very nice small
apartment.
We have recently moved further up Route 66 and into Westhampton
however this property is the permanent home of out two grown daughters
who are currently in graduate school. They intend to maintain their
possessions within and live in the property upon return. We, as parents, feel
the financial pressure and would like to have some income from the
property. We are also uncomfortable with the utility building completely
vacant.
There is plenty of parking.
The setback on one side is tight as the new road, Cardinal Way, is close to
the building. The building however was in-place about 65 years prior to the
paved road.
Very recently (early Feb), I was approached by a local lady with small
children who needed a home very rapidly. Within a mater of days she
File#BP-2007-0805
APPLICANT/CONTACT PERSON ETCHELLS MAUREEN C&MARC
ADDRESS/PHONE 125 MAIN RD WESTHAMPTON (413)203-3014 O
Ow
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: RENO&UPDATE BLDG 1 ST FLR OFFICE/WORKSHOP 2ND FLR ACCESSORY APT
IN DET STRUCTURE
New Construction
Non Structural interior renovations
_ Addition to Existing
Accesso1y 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
INFORMATION PRESENTED:
Approved 1�/ 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
� 7�
ZONING BOARD PERMIT REQUIRED UNDER: § D 7. /D,
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 Co7sion
f
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.