25C-247 (2) (I'llu 61, R_ Mr,
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12Main Street * Municipal E uilding
INS P CTop ,
Northampton, MA 01060
f-IWN7 Lml E 10-N ACILNOWLEDGEMENT
HOMEk-Y NJEREM�NIFTL _, I
The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to
-le stare defines "Homeowner" as, "'Person(s)
- _: . p�., �1.;1
act a.- h.1_,/her construction sup or- ',h LaL
act Fjwh�oovvns a parcel on which he/she resides or intends to be, a one or two fanzily
7
in., use an arm structures. A
'.11 ed or detached structures accessory to such e d/or f s Lctu.
dweffing� attach
person-who constructs more than one home in a two-year period shall not be considered a
home owner."
The building
.g.department for the City of Northampton wants any person(s)who seek to
use the home owner exemption, to act as their own construction supenrisol3 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 bac!ialL
sonotube holes (before uour) a roush building insnection (before work is
cancealed). insulation inspection (if recruired) and-aTinal-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 t.-he-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
L understand the above_
(Home owner Iresi(Yent'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
77te Commonwealth of-,Vassachraserrs
Department of Ind zstria1 accidents
�--; O rice oflrzvessi�a.zioxs
600 Washington Street
_ , Boston,U4 02111
D�� WYV7N.maSS.gOVIdZa
Workers" Compensation Insurance a-ffidaNit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeaibIv
-Name(Business/Orzmiza6on/Individuat):
Address:
City/State/Zip: Phone.:
Are you an employer?Check the appropriate box: Type of project(required):
a.. I am a general contractor and I
1.❑ I am a employer with 6. Fl New construction
employees (full and/or part-ti=ne).* have lured the sub-contractors
2.17 _ I�sied an e attached sleet.. 7. ❑Remodeling
am a sole proprietor or partner-
ship aTd have no loyees These sub-conmactors Izave g- Demoliuon
working for me in any capacity.ca en�ployees and have workers'
� 9. Building addition
[o workers'comp.msuu�ce cow.insunrance.�
required.] 5- ❑ We are a corporation and its I0.7 Electrical repairs or additions
I am a homeowner doing all work ofcers have exercised then 11.0 Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.Q Roof repairs
insurance required-]t c. 152, §1(4),and we have no
employees. [No workers' 13-7 Other
comp.insurance required.]
--' riv alp icaa ca ooz anist auo out me se non oe ow snowt¢�their woriccs'cattmens=on policy miorn:=on. --- -
Homeowners who submit this affidavit indi they are doing aB work and:hen hire outside contrac•.orz mustsubtrzit a new affidavit indicating such.
�C.ontractors that check this box nust.arached an additional she-:showing the name of the sub-contractors and state whether or not those entities have
empioyees. If the sub-canttactor have crMloye-s,they must provide their wort''-='comp.policy number.
lam 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.f: Expiration Date:
Job Site Address: City/Stare/Zip:
Attach a copy of the wormers' 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 i=osition of criminal penalties of a
fine up to SI-500.00 and/or one-year inmrisonment, as well as civil penalties in the form ofa STOP WORK ORDER and a one
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
Investisadons of the DLk for insurance coverage verification.
I do hereby certify under a' and pen perjury that the information provided above is true and correct
1 — C i ate: f
Phone#:
Officio use only. Lo not wrzte rn this area, to be completed by city or town ofjlcial
City or Town: —_ -_ ___ __---_ ----Per-mitUcense#
Issuing Authority( circle one):
1.Board of Health 2.Building Department City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,,§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...... ❑
11. - Home Owner Exemption
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-vear 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 building 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 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 Loc Zoning Laws and Stat Iassachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing ❑
Or Doors D �4 1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[O] Other[01
Brief Description of Proposed
Work:� _� Ccsr 1C L�.:J 'T,�i' `uc` c 1?+°.d cr,,.^ d C'M wt7``/
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addit`i,/on to existing housing, complete the following:
a. Use of building : One Family Je Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? IL Ir)
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
p
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
����1����s as Owner of the subject
prop rty
hereby authorize
to act on my behalf, al matters relativVtl,"authorized by this building permit application.
OV
L ,
_ _
Signatu of ner Date
L p as Owner/Authorized
Agent fiereby declare thafthe 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 o/V
Signature of gent Date
,
i
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
Setbacks Front �
Side L: R:.._. L: R: .
Rear
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 site?
NO 0 DONT KNOW Q YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ( Date Issued:
C. Do any signs exist on the property? YES NO 0
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:
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
` City of Northampton Status of Permit:
;Building Department Curb Cut/Driveway Permit
r 212 Main Street SewertSepticAvailability
t 'Room 100 Water/Well Availability
Northyonpton, MA 01060 Two Sets.of Structural Plans
ho 4 87-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO 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:
Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Etc 11.1
Name(Print) Current Mailin Address:
Telephone
Sign
2.2 Authorized Agent:
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 (a)Building Permit fee
2. Electrical 1 }Pi (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protecticn
0. Tulel-(I 1 2 1 3 1 4 1 5) (:hark Nitmhar
This Section For Official Use Only
Date_
Building Permit Number: Issued:
Signature:
- - - - -- --
Building -r- -------
Building Co mmission--- er/Ihspector ofBuildings Date
File#BP-2008-0369
APPLICANT/CONTACT PERSON BOBALA KARI&LYLE LABARGE
ADDRESS/PHONE 17 OLD FERRY RD NORTHAMPTON (413)695-1700 O
PROPERTY LOCATION 17 OLD FERRY RD
MAP 25C PARCEL 247 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 7n 62-
Typeof Construction:_SHEETROCK&INSULATE BEDROOM&HALLWAY
New Construction
Non Structural interior renovations
Addition to Existing
Accessory 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
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 Commi . n
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.
BP-2008-0369
GIs #: COMMONWEALTH OF MASSACHUSETTS
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-2008-0369
Project# JS-2008-000534
Est. Cost: $6000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 20124.72 Owner: BOBALA KARI&LYLE LABARGE
Zoning: URA Applicant: BOBALA KARI & LYLE LABARGE
AT: 17 OLD FERRY RD
Applicant Address: Phone: Insurance:
17 OLD FERRY RD (413) 695-1700 Q
NORTHAMPTON MAO 1060 ISSUED ON:1011012007 0:00:00
TO PERFORM THE FOLLOWING WORK:SHEETROCK & INSULATE BEDROOM &
HALLWAY
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 10/10/2007 0:00:00 $50.001532
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo