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212 Mam SLrt:f,, Munkipal EuEdmg
N(7 P cCT0R Nor-ttarnpton, MA 01101610
M__M E (D)W I N_E R LAS'UP T I W A C KNITO W L E D G E EIN T
T"he State of Massachusetts allows the homeowner the right under 780C-Ni1R 108.3.4 to
act her COEStrUCLOr, SZIP�-
a.- ZI-11 h ,
l . _:for. The state. defines "Homeowner" as, P erson(s)
who owns a parcel on which he!she resides or intends to be, a one or two family
d�weMng, attached or detached structures accessory to such use and/or faun structures. A
person who constructs more than one home in a two-year period shall not be considered a
home owner."
The build L_11Q d e-pax-ti-nen-tt, for the City Of Northampton wants any person(s) who seek to
use the home cvvmer exemption, to act as theur own ccristrac—Lon ssup_—,isccr, tc be awa-e
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 wore at various stares, which include foundation/footings (before ba6difl).
so-not7abe holes (before i)our). a rough building inspection(before work is
Cance'-ded). i-RS'Uhation.in-s-rjectian (if reg u fred)-and-a-finaLbuildinz insn ectio n. 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 occuDancv
until the-work-�a-be-insp-e--ted-
Ethe homeowner hires other trades to perform work (electrical, plumbing&gas) the
homeovymer 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 se-cure the permits and inspections as
require"' can DELAY the projec until such time as the propel-permits and inspections are
made"--
understand th e above.
(Home O/Iyner�/res'ident's si-natu.-e re questing exemption)
I will call to schedule all required building inspections necessary for the building permit
Issued, to me.
Date
Address of work ------_
location
i=;. �epctrtment oflndustrial Accidents
#aK
Office of Investigations
600 Uashington Street
r Boston, IYIA 02111
www.mass.;ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aoolicant Information Please Print Legibly
Name (Business/Organization/Individual): 1 >ill // c _
n
r^�uu-ess: � i,�, If�1� �1t°
City/State/Zip: C%LYG fit- I 01 c;L O Phone #: '7, 5
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
6. New construction
employees (full and/or part-time)., have hired the sub-contractors
2.❑ I am a sole proprietor 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 (❑ 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
right of exemption per MGL
myself. [No workers' comp. 1�.[ Roof repairs
insurance required.] 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.
'Ho meowners 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 nzy employees. Below is the policy and job site
information.
Insurance Company Name:
Poiicv#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
tine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
lnvestiaations of the DIA for insurance coverage verification.
I do hereby- er uraler t/teFairrs arrc�penalties-o- erlu-ry-that-the information provided above is true and correct.
Sl matui-e: r .�i. �" �-�. Date:
Phone T:
_- ,__� Official u.se ozzlDo_noLrerite-itzllris_.ar_ecz,to be cornpletezt by city_or town off_tcicrL
Citv or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Torun Clerk 4. Electrical Inspector 5. Plumbing Inspector
b. Other
Contact Person: Phone#: j
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ! a� t J� �/tifQ&ock c1`t'�)Qh9bq
License Number
GIs AUGE, e9e,&4/„0-a9,P
s / Expirati n Dater
f.
natu 50, Telephone
9.Reaistered Home Improvement Contractor: Not Applicable X,
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 Dwellines 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-year 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 buildine 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, Sxa 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 W' dows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [ED] Decks Siding [ Other[O]
Brief Description of Propose
Work: d2a) fly/r W(ill0% 1S . Chi)QS v :3Z0I(J Cam'
Alteration of existing bedroom Yes V No Adding new bedroom Yes __ZNo
Attached Narrative Renovating unfinished basement Yes ✓No
Plans Attached Roll -Sheet
6a.if New house and or addition 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
I, , 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'
d f .3 , V .P� ,.i0 E.r.• �,.�f� G�J G�}J�
ignature of O ner/Agern `�, 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
Lot Size i a I�i'�_ . PT,
t� o
Frontage 7J
Setbacks Front J
Side U615' R: ��1 L: R:
Rear 102
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved l-Li1
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Re stry of Deeds?
NO DONT KNOW �Q YES C)
IF YES: enter Book Page' Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW U YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , 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:
E. Will the construction activity disturb(clearing,grading,exc ation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES I 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 CuUDriveway Permit
r `+ Main Street Seer/septic Availability.
n\
Room 100 Watermall Availability'
Northampton, MA 01060 TWO Sets of Structural Plans
phone 41.3-587-111240 Fax 413-587-1272 Plot/Ste Plans
Other Specify
'"-A-OPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
11',�l ft-A1 < �" Map Lot Unit
1-t -09- Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print), Current Mailing Ad res
N13
Telephone
Signature
2.2 Authorized Agent:
00 L) 11qC N 3A V7 0 S M6 14OL.VO K , hA .
e(P t) Current Mailing Address:
H12 . 53.39b3_S
Signature I Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building Oc�C�,1 l0 (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=(1 +2+3+4+5) ((7 to. Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
„qS ;. BP-2008-0727
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
I.Cr„it: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category. BUILDING PERMIT
Permit# BP-2008-0727
Project# JS-2008-001141
Est. Cost: $0.00
Fee: $75.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 8886.24 Owner: ROBINSON ANN
zonin : URB Applicant: ROBINSON ANN
AT. 182 MAIN ST
Applicant Address: Phone: Insurance:
142_JARVIS AVE (413) 534-9734 (�
HOLYOKEMA01040 ISSUED ON:212812008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS,DOORS,
SIDING & NEW 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:
FeeTvpe: Date Paid: Amount:
Building 2/28/2008 0:00:00 $75.006384
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo