23A-094 City of Northampton '
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS m
212 Main Street • Municipal Building
Northampton, MA 01060 S
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 sha not be considered a home owner."
The building department for the City of Northampton wants any pers (s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be ware 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 inspot work at various stages, which include
foundation/footings (before backfill), sonotube holes (bbeef6re pour), a rough building inspection
before work is concealed insulation inspection if re fired and a final building inspection.
The building department requires,these inspections before./he work is concealed, failure to secure
these inspections can result in failure to obtain a ce ficate of occu anc until the work can be
inspected.
If the homeowner hires other trades to"perform work ectrical, plumbing & gas)the homeowner will be
responsible to make sure that the trades`tlired secur their proper permits in conjunction to the building
permit issued, and that they get their req'ttired i pections. Failure of the individual trades to secure
the permits and inspections as required can E Y the project until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner/resident's signature r uesting`'exemption)
I will call to schedule all required buildin nspections rfe.cessary for the building permit issued to me.
Date
Address of work location
tr
` The Commonwealth of Massachusetts
Department of Industrial Accidents
J
Office of Investigations `
600 Washington Street
Boston,MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
(Business/Organization/Individual): "� ac�� \ �f
Name J L �r"-�,..� C")VVC-E"i-AC_T'11)
Address: ? V Gl ;7 r
City/State/Zip:����r �- Phone#: (417
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 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2 1 am a sole proprietor or partner- listed on the attached sheet. 7.;® Remodeling
-- -- have h
a
ship and have no employees These 8. E] Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp.insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 13.❑ 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.
tContractors 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
informatcon.
Insurance Company Name: � ��✓
Policy#or Self-ins.Lic.#:VJ CC. S°rt;p 5"'a 4G 2-90 Expiration Date: k.�
Job Site Address: [` SV r/t v)- ST' Azla City/State/Zi - --U '' t1C t, �* y 1 yt
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 pa's and penalties of perjury that the information provided above is true and correct.��� Date: 1 14
Signature:
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 Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
ry
SECTION 8-.CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: v '= \l`� C—5 053 ,S—)
License Number
Address Expiration Date
C,lC�
Signature Telephone
e 6860-69M cne m rovemen ontractor Not Applicable ❑
Company Name ! Registration Number
_e- v-z �i� C-1)gin( cr (v� /n f Z Z`}-
Address Expiration Date
ly1 �6 V
L ItNt- `j\ t�y'�e t1CP Telephone 4t' l G - z S
nSE C
TION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MEGL c e153,§25G(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...... ❑
°0�1���Wt1 ��11�p�1D>ll
The current exemption fbn "homeowners"was extended to include Owner-occ ed Dwellings of one(1) or two(2)families
and to allow such homeowi*to engage an individual for hire Zonch ssess 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 lae resides or intends to reside;,, which there
is,or is intended to be,a one or two family dwelling,attached tures accessory to such use and/or farm
structures.A erson who constructs more t an one home in od shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official, a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the,k iilding 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 pe issued.
Also be advised that with reference tgLerapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resu g in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work,fert 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 Massachuse General Laws Annotated.
Homeowner Signature '
r
J
A
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all app licabiel,.,,a _ e
7 •�
i
New House ❑ Addition ❑ Replaceme t dows Alterations) ❑ Roofing E]Or Doors en
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[O] Other[[J]
Brief Description of Proposed S������� �`� 1
Work: irr,2�y1/� \'�'c5�Uv_ 1M s 4�t
FL---�o y 4. —,Alteration of existing brdrom
es No Adding new bedroom Yes `X No
Attached Narrative Renovating unfinished basement Yes `>f- No
Plans Attached Roll -Sheet
a f ew se=and o> aRai on to exi"s i RPM st I comp a e: he�fiON ow :
a. Use of building : Q�e Family Two Family Other
b. Number of rooms in each family unit: Number of Bat corns
c. Is there a garage attached?
d. Proposed Square footage of n6l construction. Dimensions
e. Number of stories?
f. Method of heating? LZFireplaces 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 be finished grade
k. Will building conform to the Bui ing and Zoning regulations? Yes No.
I. Septic Tank City ewer Private well 'Clity water Supply
SECTION 7a.OWNER AUTHORIZATION ,TD BE COMPLETED_,WHENN
OWNERS AGENT OR CONTRACTOR APPLIES FOR`BUILDiNG PERMIT
I, S\hyye Fy,�rL &A / klr\ as Owner of the subject
property f
�?
hereby authorize � t�—�- lJ o�
r.
to ac my behalf, in all matters lative tolwork authorized by this building permit application.
/
Sig nature of Owner Date
as Owner/Authorized
Agent hereby declare that the Ltatements 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.
Print Name
Signature of wner gk Date
r
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by'Loning
This column to be filled in b$j( "` `y
A*
Building Department
Lot Size
Frontage
Setbacks Front
Side L:= R•1 L:1 R:5 ---a t��!
Rear
I r I
Building Height
Bldg.Square Footage
- 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 syte?
NO DONT KNOW U YES 0 f
IF YES, date issued:;. '
IF YES: Was the permit,recorded at the Registry of Deeds?
NO DONT KNOW YES
f IF YES: enter Book Page and/or Document#i
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 bbtain4d , Date Issued:
C. Do any signs exist on the property? YES ,. NO 0
IF YES, describe size, type and locati6n:
D. Are there any proposed changes to;tSr additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type anfc /location
E. Will the construction activity dist�j rb(clearing,grading,excavation,or flling)''bver 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northamptoq-8torrn Water Management Permit from the DPW is reoired.
s
City of Northampton S us o Perri
Building Department
Z 212 Main Street Se .e I rra lr
u�
Room 100
Electric, Plumbing&Gas InspectfoN rthampton, MA 01060 ;
Norrt,arooton, M -587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION T-SITE INFORMATION .
1.1 Property Address: yk
Thissectrontobecompietedby.;.;office= � � � �
4 J ` ( , t Ate, �/�
c.7 v ✓• \ Y �� \ 5sb>' •. 3. ay 1? a. xsc.�. .. t x
��"V V� "�����.. —� \ rl I I ♦ (��F.' Y��� ,z 4 ts.' x''S�5�'ri��Y �3"�� '�'#�k k, � � �"",v"1.�'��h.
SECTION 2 PROPERTYFOWNERSHIP%AUTHORIZED AGENT
2.1 Owner of Record:
Namd jPrint) Current Mailing Address:
-mss
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
S' natur Telephone
SEC 3='ESTIMATED CONSTRUCTION COSTS` _
Item Estimated Cost(Dollars)to be Official Use Only
completed b permit applicant ' A
1. Building (a)Building PermttFee '
2. Electrical (b),Estimated TotalrCosf of
Constriction from,6
3. Plumbing Bid dlln4'ft t,Fee
4. Mechanical(HVAC)
v z
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Onl'
Building Permit Number Date
IssuecJ
Slgpature.-
Building Commis sionerllnspectorof,Buildings Date
File#BP-2014-1142
APPLICANT/CONTACT PERSON JEFFREY BOTT
ADDRESS/PHONE 32 Pine Street FLORENCE (413)530-6920 Q
PROPERTY LOCATION 18 SUMNER AVE
MAP 23A PARCEL 094 001 ZONE URB(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
Tvneof Construction: SHEETROCK BEDROOM&INSTALL 2 REPLACEMENT WINDOWS au/'
New Construction
Non Structural interior renovations 6
Addition to Existing
Accessory Structure
Buildina Plans Included:
Owner/Statement or License 053157 V1 n J
3 sets of Plans/Plot Plan
jFO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
ATION 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
Demolition Delay
Sig re of ilding 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.
18 SUMNER AVE BP-2014-1142
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A-094 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2014-1142
Project# JS-2014-001934
Est. Cost: $4000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JEFFREY BOTT 053157
Lot Size(sq. ft.): 5314.32 Owner: LIEBMAN JONATHAN B&ANNE FINE
Zoning: URB(100)/ Applicant: JEFFREY BOTT
AT: 18 SUMNER AVE
Applicant Address: Phone: Insurance:
32 Pine Street (413) 530-6920 () Workers Compensation
FLORENCEMA01062 ISSUED ON.51512014 0:00:00
TO PERFORM THE FOLLOWING WORK:SHEETROCK BEDROOM & INSTALL 2
REPLACEMENT WINDOWS - energy star 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 5/5/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner