12C-110 (2) 1.
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 7$0 MR 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 two family
dwelling, a ched or detached structures accessory to such use or farm structures. A
person who c structs more than one home in a two-year pen shall not be considered a
home owner."
The building departmept for the City of Northampton ants person(s)who seek to use
the home owner exemptiop,to act as their own cons ction supervisor, to be aware that
by doing.so you become r onsible for compli ce with state building codes and
regulations. The inspection p cess requires t the building department be called to
inspect work at various stages, ch includ oundation/footings (before backfill),
sonotube holes before our a u h b din ins ection before work is
concealed insulation inspection re ired and a final buildin2 inspection. The
building department requires these ins coons before the work is concealed, failure to
secure these ins ections can result/in ffilure to obtain a certificate of occu anc
until the work 7ine ected
If the homeowher tr des to perfo work(electrical, plumbing&gas) the
homeowner wisib a to make sure th the trades hired secure their proper
permits in conj building permit issue and that they get their required
inspections.Faindividual trades to secur the permits and inspections as
required can Dproject until such time as the roper permits and inspections are
made
I, nderstand the above.
(Home ow er/resident's signature requesting exemption)
I will call to chedule all required building inspections necessary for the building permit
issued to
Date
Address of work
location
J.,.
r >
"` . The Commonwealth of Massachusetts
Department oflndustrialAccidents
F.
Office bfInvestigations
f 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): A 6
Address: go
City/State/Zip: Phone#: 1:� - �3 j c/o J
Are you an employer?Check the appro rate box: T3 pe of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
W have hired the sub-contractors 6. ❑New construction
employees (full and/or part-time). •
2.[ I am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolitions
working for me in any capacity. employees and have workers'
9. ❑Building addition
[No workers'comp.insurance comp. insurance.
required.] 5. F-1 officers have exercised their We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work 11.El 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 /11,9W,
comp. insurance required.] a 1 6
`Any applicant that checks box#I 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:
Policy#or Self-ins.Lic. #: 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 np 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.
Sienature: /�%;'��` '1 G � Date: ' ®f ,
Phone#:
O,ficial 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#:
1
Aft
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: / rLr 0,)/J✓4YT44 �2 (J &2 1r�2
-�- License Number
At zz)
Address j Expiration Date T
^' z
Signature Telephone
9.Re4ister6 Hoir 6Am[iroueri�enf Coii#ractor „A _. .. Not Applicable ❑
,,
Company
Name
�A Registration u nb r
Address Q Expiration Date
�✓S ✓�� � - ( C9- Telephone3�
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MG.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....... 1� No...... 1°
11. ;Home Owi a "E n
The current ex lion for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such ho owner to engage an individual for hire who does not possess a license,providi6d,that the owner acts
as supervisor.CMR 786',-Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Peraon(s)who own a parcel of land on which he/she resi r intends to reside,on which there
is,or is intended to be,a one or two Family dwelling,attached or detached es accessory to such use and/or farm
structures.A person who constructs more` an one home in a two- eriod shall not be considered a homeowner.
Such"homeowner"shall submit to the Building`Official,on a fpRiracceptable to the Building Official,that he/she shall be
responsible for all such work under th u' n-2 Dermit.
As acting Construction Supervisor your presence e. site will be required from time to time,during and upon
completion of the work for which this permit i ' sued.
Also be advised that with reference to C er 152(Workers'Comp ation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting eath)of the Massachusetts Gener Laws Annotated,you may be liable for person(s)
you hire to perform work for yo rider this permit.
The undersigned"homeow 'certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinanc , State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
y
SECTION 5-DESCRIPTION,OF PROPOSED'WORK-(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [[--3] Decks [C] Siding[O] Other
Brief Description of Proposed
Work: RiZ✓"1tJrlow �c(srlr✓�— l<l fe CV4 wit/0*1,rS R6 I)h>�c�. i LJI�/� !il�c�CtJ�,jf4
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
&a. If New house and;or addition to existing housing, complete'the following:
a. Use of b uild, One Family Two Family Other
b. Number of rooms in ea amily unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensi s
e. Number of stories?
f. Method of heating?. Fireplac or Woo s Number of each
g. Energy Conservation Compliance. M scheck Energy Compliance o ttached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? es No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor belo ished grade
k. Will building conform to the Bui ng and Zoning regulations? Yes No.
1. 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
(2A 1 i;-7- 7- 4 �) �Ll as Owner of the subject
property r�
hereby authorize / fl d�rV 6),V/V7 �7t �✓
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner.- -----___-- ---- _ _ ----_- _--.__---Date
� �`J (�� ✓�u ,, , j _ , 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.
/ A /V /Y y;'4
Print Name -
Signature of Owner/Agent Date
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
IQJLot Size _____._ __.._.... _ ._,,._- _.._.,... _.._ ._ ____.._.. ......_.......
Frontage
Setbacks Front _
Side L:'
Rear
Building Height
Bldg.Square Footage __ %
Open Space Footage % M ``
(Lot area minus bldg&paved
parking)
1
#of Parking Spaces
Fill:
(volume&Location
A. Has a Special Permit/Variance/Fin'ding 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 ._ g
Pa ew, and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW y 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 0 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,gradingi%excavatioiT, 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.
1
�► s
" • '' .� � � Departmerxt use�n�� � `
City of Northampton StatusVaf Permlts
Building Department Curb Cutlta�yewaY Perrnrta x "
212 Main Street Sewer/se cA artabiCtty �
a " e
Room 100 Wa ertu�tellvatrata�ty
Northampton, MA 01060 ytc $dIs ofStW aztPlani
phone 413-587-1240 Fax 413-,.58.7_-1272 Site tans
APPLICATION TO CONSTRUCT,ALTER,REPAIR,t NOVATE OR DEMOLISH A 6NE�OR TWO FAMILY DWELLING
APR 2 1 2009
SECTION 1 -SITE INFORMATION
_ This section to be completed by office
1.1 Property Address: i
Map_, Lot Unit
/)0 P-4 4 VA I'l 13-y-v sti 1 ul /9 S j Zone Overlay District
r
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
1-��L \C�.L �IIJ� (R��f1�(l41✓� �UV �� �! � IG� I> LL
Name(Print) Current Mai ing Addr
n' ss -7�J -U
�{.,�� 1I
Telephone
Signature
2.2 Authorized Agent:
Q h)A N G Ht.d
Name(Print) Current Mailing Address:
7 j
`-�13 613-- �t�-7y
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. Building (a)Building Permit Fee L, U u
2. Electrical (b)Estimated Total Cost of a�
Construction-fram 6, -
3. Plumbing Building'Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissionerlinspector of Buildings Date
69 RICK DR BP-2009-0844
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc : . 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-2009-0844
Project# JS-2009-001255
Est. Cost: $0.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Bonneau Builders 016124
Lot Size(sq.ft.): 10497.96 Owner: SOTO HECTOR L&CARMELITA TORRES
zoning_:URA(100)//RI/WSP Applicant: Bonneau Builders
AT. 69 RICK DR
Applicant Address: Phone: Insurance:
88 Rambling Road
AMHERSTMA01002 ISSUED ON.
TO PERFORM THE FOLLOWING WORK:rempve existing kitchen cabinets & replace with
new cabinets and countertops
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 4/21/2009 0:00:00 $55.009478
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo