36-040 (4) City of Northampton
f ,_,•� \ �S�s :::sir
Massachusetts
j ; Y DEPARTMENT OF BUILDING INSPECTIONS >L
�s' y 212 Main Street • Municipal Building
C
Northampton, MA 01060
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 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 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 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 Massachusetts
r Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
µ www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: :�E_ r 5/X C /_/ fly-5yt/
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 (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.�El I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ 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.E] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.E] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.aRoof 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.
tHo meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors 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: Na T)U�1AC G C,q► N ytC
Policy#or Self-ins.Lie. #: to P F X'15' 'C Expiration Date: 1 L Z, I 1�f
Job Site Address: City/State/Zip: o103'h
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.
Signat ure: 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 Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
i .
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction�S"upervisor: Not Applicable E
Name of License Holder: lza-A,.d CS 6tj 0?0I/
License Number
n 44
Address Expiration Date
W
S gnature Telephone
9.Registered Im
ome' provement Contractor: Not Applicable £
H
Company Name Registration Number
S --Pi
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors lJ I i
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Deck [M Siding [❑] Other[❑]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ba. If.New,house and or.addtion 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
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
I , 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.
Print Name
Signature of Owner/Agent Date
'
�
Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
T'bis column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Ut area minus bldg&paved f-------
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Yahance/Flnding ever been issued for/on the site?
NO 0 DONTKNOY - YES 0
|F YES, date issuedd |
IF YES: Was the permit recorded atthe Registry of Deeds?
NO K ] DONTKNOYY YES`~- _
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body nf water orwetlands? NO DONT KNOW 0 YES
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs to be obtained �-x Obtained �~� Date Issued:
�-� v_� '
C. Du 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 0 NO 0
IF YES, describe type }
' '
E. VW||the construction activity disturb(clearing, gradingexcavation, or filling)over 1 acre oriait part ofa common plan
' that will disturb over 1acre? YES NO
|F YES,then a Northampton Storm Water Management Permit from the DPW isrequired.
r
Department use only
of Northampton eta ua ofPermd s �' "" 'r
MAY 302014 ilding Department ct�r Cut/Drlue�uayPerrrti#` kF
t 1 �
12 Main Street SevrerlSepticAva�fa6jll{y '
Flec`r F k Gas inspections
Room 100 Vllater/UtleifArratlabllity
60 ampton, MA 01060 Twa sets oftruc#riral Plans
phone e 413-587-1240 Fax 413-587-1272 PIof/Site Pians � r F
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This seciwn.t...o b_.
e completed by office.
1(y G r1- 13u 0 , Q I T 9A. .Map Lot Urnt
u "AF =Zone Overla District
y
Elm St Distnct
EM". Distract
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: L N
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
-
:T OEJ TV I T' �t7U� m14
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 r5 (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=0 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building CommissioneOnspector'of Buildings: Date
1067 BURTS PIT RD BP-2014-1278
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-040 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2014-1278
Project# JS-2014-002147
Est.Cost: $5800.00
Fee: $70.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RONALD KEITH 085204
Lot Size(sq. ft.): 12501.72 Owner: EKLUND ALLEN C&VICTORIA A
Zoning: Applicant: RONALD KEITH
AT. 1067 BURTS PIT RD
Applicant Address: Phone: Insurance:
5 BIRCH MEADOW DR (413) 584-5589
HADLEYMA01035 ISSUED ON:61212014 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF
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 6/2/2014 0:00:00 $70.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner