25C-198 (4) 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 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 ow /resident's signature requesting exemption)
I will call to sche all required building in necessary for the building permit
issued to me.
Date
Address of we
location
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office bf In vestigations
600 Washington Street
�y
_ Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers
Applicant Information Please Print Legibly.
Name (Business/Organization/Individual):
Address: -ct M-5;
t�tv3
City/State/Zip: 1 d ``�ti I ae, Phone #: q13 -
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. I am a sole propri etor or partner- listed on the attached sheet. 7. [] Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. employees and have workers' 9. D 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 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no 131-1 Other employees. [No workers'
comp.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.
'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
employee`s. 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. Lie. #: 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
cf up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi under the paihLs$ndpep1ties of perjury that the information provided above is true and correct.
Signa� tur_ems_ .�t -- Date: 41!3k
Phone#: t"
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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: « `—�&�:541 e 7 3 V j Q
License Num er
Address Expiration Date
Signature Telephone
9.Registered Horne ImPr¥ eiit Contractor:` Not Applicable ❑
Company Name � Registration Number
Address , Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 162,§'26C(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....... rd di No...... ❑
11. Home Dwrier'Egem ton
The current exe on for"homeowners"was extenE o inc a Owner-occupied Dwellings of one(1) or two(2)families
and to allow such hom ner to engage an individu i e who does not possess a license,provided that the owner acts
as supervisor.CMR 780. h Edition Section .5.1.
Definition of Homeowner:Perso who o 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 fam elling,attached or detached structures accessory to such use and/or farm
structures. A person who constructs ore tha a home in a two- ear period shall not be considered a homeowner.
Such"homeowner"shall submi the Building Offici , n a form acceptable to the Building Official,that he/she shall be
responsible for all such erformed under the buildin rmit.
As acting Construe " Supervisor your presence on the job site wt required from time to time,during and upon
completion of work for which this permit is issued.
Also be ised that with reference to Chapter 152(Workers'Compensation) an apter 153 (Liability of Employers to
Em ees for injuries not resulting in Death)of the Massachusetts General Laws Annotat you may be liable for person(s)
u 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 Wjpdows Alterations) Roofing
Or Doors 92T
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [0 Siding[0] Other[M"-4 o
S
Q f
Brief De ription of Proposed
3ork O;V
ta►QowS �Ry�( . tall,
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ,,/N o
Plans Attached Roll -Sheet
sa. If New se and or addition fo:existing housing cornlplete the following
a. Use of building : e Family Two Family Other
b. Number of rooms in each mily unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new constructid Dimensi
e. Number of stories?
f. Method of heating? Fir ces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck-ECrgy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wet s? Yes No. Is construction within M yr. floodplain Yes No
j. Depth of basement or r floor below finished grade
k. Will building c form 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 �_ 1 S k-n-,;' G(rd4-ln -I c-z as Owner of the subject
property �..-
he y a thorize r%-tGe- /0,-5.
�✓
t act on y behalf, in all matters relative to o thonzed by this building permit a placation.
Sig of Owner Date
B ��L -�5;C4 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 nder the pains and penalties of perjury.
Print Nam
Signature of Owner/Agent Date
r
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
a
Lot Size __ _....__.! ... ., _._,.. .
Frontage
Setbacks Front
Side L: _. _..... _.._, L......—R"-
Rear
Building Height
Bldg.Square Footage % _........_.
Open Space Footage % _._..,,.
(Lot area minus bldg&pave
arkin �..-
#of Parkin aces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW � YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 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 YES
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 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO
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 0 NO G
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
• fl,,.
Department use D.
` r�l oi'Northampton status of F66:nit
� a
Building pepartment Curb Cut/D�r)veway Permit
Qo212 Main,Street se�nier/se trcAvao-labt fy
atom 00 Waterf{iUell Ayailabllrtyy
Northiapton, 01060 Two,sets of Structural Plans
'
phone-�k -?l_ Fax 413-587-1272 Plotfs}te Mans `
�.r' r �" 4tl7er.Specify
AP0,LICATIOI$�fO 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:
5+rec. - Map Lot Unit
vJ1 t ft'�l Zone Overlay District
Elm St.District C13 District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
P a• 13o
me Print Current ili g Ad 4rus:
Telephone
' nature
2.2 Authorized Accent:
�fY♦ C'C
Name(Print) Current Mailing Address:
4-1 3 '�
s
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building a)Building Permif Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit'Fee
4. Mechanical(HVAC)
5. Fire Protection
c Check Number
6. Total=(1 +2+3+4+5) U�This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
r
File#BP-2009-1054
APPLICANT/CONTACT PERSON BRUCE TAUSCHER
ADDRESS/PHONE 54 ADAMS RD HAYDENVILLE (413)268-3814
PROPERTY LOCATION 59 NORTH ST
MAP 25C PARCEL 198 001 ZONE URC(100)/
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: INSTALL REPLACEMENT WINDOWS&DRYWALL CEILING IN 3 SEASON PORCH
&INSTALL WOODSTOVE
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License 087399
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFgYMATION 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
4/� O6 LZ 3 o
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.
f' BP-2009-1054
GIS#: COMMONWEALTH OF MASSACHUSETTS
98 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-2009-1054
Project# JS-2009-001534
Est. Cost: $11400.00
Fee: $68.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BRUCE TAUSCHER 087399
Lot Size(sq. ft.): 5967.72 Owner: D'ERRICO VAN GORDON LISA&BRUCE MICHAEL MACMILLAN
Zoning URC(100)/ Applicant: BRUCE TAUSCHER
AT. 59 NORTH ST
Applicant Address: Phone: Insurance:
54 ADAMS RD (413) 268-3814
HAYDENVILLEMA01039 ISSUED ON.612412009 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS &
DRYWALL CEILING IN 3 SEASON PORCH & INSTALL WOODSTOVE
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 6/24/2009 0:00:00 $68.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo