24D-307 (4) City of Northampton
Massachusetts ;
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building � �k
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The to of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to t as his/her
construc n supervisor. The state defines "Homeowner" as, " Person(s) who owns arcel on which
he/she rest s or intends to be, a one or two family dwelling, attached or detac d structures
accessory to ch use and/or farm structures. A person who constructs more th one home in a two-
year period sha of be considered a home owner."
The building departme for the City of Northampton wants any person who seek to use the home
owner exemption, to act a their own construction supervisor, to be are that by doing so you
become responsible for co liance with state building code and regulations. The inspection
process requires that the buildin department be called to insp t work at various stages, which include
foundation/footin s before bac ' I sonotube holes b ore ours a rou h building inspection
before work is concealed insulat n inspection if r uired and a final building inspection.
The building department requires these i ections bef a the work is concealed, failure to secure
these inspections can result in failure to tain a ertificate of occupangy occupancy until the work can be
inspected.
If the homeowner hires other trades to perform (electrical, plumbing & gas)the homeowner will be
responsible to make sure that the trades hire ecur heir proper permits in conjunction to the building
permit issued, and that they get their req red inspec Ions. Failure of the individual trades to secure
the permits and inspections as required n DELAY the pr ' ct until such time as the proper permits
and inspections are made
I, u erstand the above.
(Home owner/resident's ignature requesting exemption)
I will call to schedule all re fired building inspections necessary for the b Iding permit issued to me.
Date
Address of work I ation
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
•r
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): q (re O ` _
Address: 9 2— //1 &1 5-7'
City/State/Zip: 7�L 0 IZE 17 C--- M Phone#: :53
Are you an employer?Check the appropriate box: Type of project(required):
1.Z 1 am,a e—ployer With 1 _ 4. ❑ I am a general contractor and I - F-1 i�ew canstructivn
employees(full and/or part-time).* have hired the sub-contractors o.
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
-- sub-contractors have ship and have no employees These 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp.insurance.1
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' 1311 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: A it-1
Policy#or Self-ins. Lic.#:V)LL 500 54D DOD`f A/i Expiration Date: 6
- --Job Site Address: J?f Olt1L-Lvof!!� 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: _ Date:
Phone#: 6� 7—3
-` Official use only. Do not write in this area, to be completed by city or town official
City or Town: PermitlLicense#
Issuing Authority(circle one):
R—r d of Health 2.u,u ldi,^.°Tlonartmant 2, r'ity/rnwn Clerk 4: Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
OP
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: + Not Applicable ❑
(� �''t. / L5 0tj. 31 S7
Name of License Holder: (.�
License Number
Address _ Expiration Date
9 2_0
Sig ture Telephone
Not Applicable ❑
.9.Re4istered�lome.lmarovemen�°Contractor�Yy „�,�; r�g<�e ,�, ,.�,���� ��,�„_� y�:•
0 12-2-1
Company Name Registration Number
Address Expiration Date
Telephone530 6 9
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,"G L c .452,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
.+ SEE$' .A`
11 - oineZermp, o.n
The current exe ion for"homeowners"was extended to include Owner-oceu ie wellin s of one(1) or two(2)families
and to allow such ho owner to engage an individual for hire who does not pons s a license,provided that the owner acts
as supervisor.CMR 78 ixth Edition Section 108.3.5.1.
Definition of Homeowner:Pe (s)who own a parcel of land on which /she resides or intends to reside;on which there
is,or is intended to be,a one or two ly dwelling,attached or detach structures accessory to such use and/or farm
structures.A person who constructs mor an one home in a two- ear Deriod shall not be considered a homeowner.
Such"homeowner"shall submit to the Buildin fficial,on a fo cceptable to the Building Official,that he/she shall be
responsible for all such work erformed under t buildin ermit.
As acting Construction Supervisor your presence on t 'o ite 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(Wo ers' pensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the assachusetts neral Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit
The undersigned"homeowner"certifies and ass es responsibility for comp e with the State Building Code,City of
Northampton Ordinances,State and Local Zo ng Laws and State of Massachusetts eral Laws Annotated.
Homeowner Signature
J
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) r
New House ❑ Addition ❑ Replacemer t�Windows Alteration(s) ® Roofing ❑
Or Doors ]
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[0] Other[0]
Brief Description of Proposed
Work: P—g-o 10 V-c, t'�t(V)R R4T[!B Ze>m ��E9 tzooWk 'A i c, M&5mg SOT
Alteration of existing bedroom_XYes No Adding new bedroom Yes �_No
Attached Narrative Renovatie9 unfinished basement Yes No
Plans Attached Roll -Sheet
Sa..If ewl ouse.and,,or.addition toxex�stin housin com ietethe:fo owin'°:
a. Use o ilding :One Family Two Family Other
b. Number of roo s in each family unit: Number of Bat oms
c. Is there a garage atta d?
d. Proposed Square footage of n 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 w nds? Yes No. onstruction within 100 yr. floodplain Yes No
j. Depth of basement or cellar oor below finished grade
k. Will building conform t e Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a OWNER.AUTHORI7ATION=TO BE COMPLETED_,WHEN
.OWN"NERS AGENT ORiCONTFtkCToR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property L
(�
hereby authorize
to act on my behal in all ma s relati to work authorized by this building permit application.
Signature of 5wrier Date
V-'P as Owner/Authorized
Agent hereby declare tha 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.
��- e-�w-e-!-, �
Print Name
Signat .e er/Agent Date
A
r
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required bytning
This column filled in by
1 r 1 i Building Department
ent
Lot Size !
Frontage
Setbacks Front '
Side L:= L: I
Rear
Building Height
Bldg.Square Footage %
i
_ Open Space Footage
(Lot area minus bldg&paved 4
parking)
7-7#of Parkin Spaces
i
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:`
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Vn YES 0
IF YES: enter Book = Page; I and/or Document# j
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW (D YES 0
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 0 NO
IF YES, describe size, type and location s
E. Will the construction activity disturb(clearing,grading, avation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton S#atus o Permits fi
D Building Department
212 Main Street Sesser epicallaiit(t � �� �_
A 2 12014, Room 100 1Na�er�Well=Ayarlabutty � ���� ;� "
Northampton, MA 01060 tvrc'Se Strli , tYr,�,, ��
I 413-587-1240 Fax 413-587-1272 Plo St tart
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1--SITE INFORMATION
1.1 Property Address: k
This section to be completed by office
fJ c7 T qA vn C O
� Overlay D�str�ct
Elni St.District" "CB District:.
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
t-_)j?(j:rj t-1Atyw)p
Name(Prin Current Mailing Address:
Telephone e�
Signature S r� 07 4+6
2.2 Authorized Agent:
Name(Print) lk Current Mailing Address:
Si atu Telephone
SEC N 3=ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)`Building Permit
D Fee
i
2. Electrical (b) Estlmated Total Cost of
Construction from 6
3. Plumbing 6-7 Buwldmg Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) (9 at9, OrJ Check Nurrtber ..
T his Section For:Official Use Onl `.
Building Permit Number Date
Issued.
Signature. .
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0089
APPLICANT/CONTACT PERSON JEFFREY BOTT
ADDRESS/PHONE 32 Pine Street FLORENCE (413)530-6920 Q
PROPERTY LOCATION 18 HILLSIDE RD
MAP 24D PARCEL 307 001 ZONE URA(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE
Fee Paid
Building,Permit Filled out
Fee Paid
Tvneof Construction: REMODEL BATHROOM/BEDROOM INTO MASTER SUITE
New Construction
Non Structural interior renovations f
Addition to Existing /k,a
Accessory Structure QI/e
C CS
Building Plans Included: p
Owner/Statement or License 053157
3 sets of Plans/Plot Plan L&Zh!6 LC l
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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
e n Delay
Si ature of Build' g fici 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 HILLSIDE RD BP-2015-0089
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D-307 CITY OF NORTHAMPTON
Lot: -00 1 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv:renovation BUILDING PERMIT
Permit# BP-2015-0089
Project# JS-2015-000152
Est. Cost: $19200.00
Fee: $115.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JEFFREY BOTT 053157
Lot Size(sq. ft.): 21257.28 Owner: BROWN HENRY
Zoning. URA(100) Applicant. JEFFREY BOTT
AT: 18 HILLSIDE RD
Applicant Address: Phone: Insurance:
32 Pine Street (413)530-6920 () Workers Compensation
FLORENCEMA01062 ISSUED ON.712412014 0:00:00
TO PERFORM THE FOLLOWING WORK.REMODEL BATHROOM/BEDROOM INTO
MASTER SUITE - update smoke/co's current code
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:
FeeTyve: Date Paid: Amount:
Building 7/24/2014 0:00:00 $115.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner