17A-043 (2) 3 � � ,�assacf�uscffs I, f f
DEPARTMENT OF BUILDIIG INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMP'T'ION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sup,.: . ssor. 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 any 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_finaI_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 owner/resident'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
The Commonwealth offftassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov%dia
Workers' Compensation Insurance Affidavit: Builders/Contlractors/Electricians/PIumbers
Applicant Information Please Print Leilibly
Name(Business/Organization/Individual): WINDOW
WORLD
Address: 56 Dimock Street
Leeds,MA 01053
City/State/Zip: Phone#: 586-8712
F�_re you an employer?Check the appropriate box: Type of project(required):
.❑ I am a employer with 4. F-1 I am a general contractor and I
loyees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.[ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no ezrTloyees These sub-contractors have 8. Fj Denolition
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 10.0 Electrical repairs or additions
3.❑ 1 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
employees. [No workers' 13.0 Other
comp. insurance required.]
'any app-lithat checks box 41 must also tin 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 subcontractors 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 up to S 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
Signature Date 7-
Phone T
Phone#: --_9'C: a 7/ A---
LOther onry. uo not write in this area,to be completer!by city or town official
n: Permit/License#
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
S-Reaistered Home_Improvement':Confractor ;: .: u „ „-{ Not Applicable ❑
Company Name WINDOW WORLD Registration Number
56 DimnEk Sure` lA a
Address Leeds,MA 01053 Expir tion Oate
586-8712 Telephone
SECTION 10 WORKERS'COMPENSATION INSURANCEAFFIDAVIT(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....... ❑ No...... ❑
on.
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-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,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 ❑ ReplacementiWjpr#ows Alterations) ❑ Roofing ❑
Or Doors o
Accessory Bldg. ❑ Demolition ❑ New Signs (01 Decks Siding[0) Other ft:J
Brief Description of Proposed--
Work: -- S/!i-1 L. 1/ia-y t! i-ePL R Co—� Ci,Jt-i i 5 Cl 1/f}Li,+� . .3 �f
Alteration of existing bedroom Yes No - Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a_IfAi house and or-acictition'to ezistina ousrnrfr,cci t?1 ete:f61.fo[[bW1nc:
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 o. s cons ru ion wi in --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
as Au
ge ereby declare that the statements and information on the foregoing application are true and accurate,to the best of
an elief.
Signed under the pains and penalties of perjury.
Print Name
le 7
Ltd
Signatur caner gen 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
Frontage
Setbacks Front
Rear
Building Height
Bld-, Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A Has a Special Perm it/Variance/Fi nding ever been issued for/on the site?
NO C) BGN'T 10199f n YES Q
IF YES, date issue&
-------
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 OON7KNOW 0 YES
IF YES: enter Bonk | Page / and/or Document#'
�� ��
B. Does the site contain abrook, body nf water orwetlands? NO �~��/ DON7KNOVV �_/ YES �_�
IF YES has o permit been ur need to be obtained from the Conservation Commission?
Needs tobeobtained v-\ Obtained �=x_�� Qate ]ssued' � '
v�� ' �
C. Dn any signs exist on the property �� ��� YES v�� NO �~/
IF YES, describe size, type and |ucodun:
D. Are there any changes to ur additions u signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location: '
E. Will the construction activity disturb .grading,excavation,or filling)over 1 acre nrisd part o[o common plan
that will disturb over 1acre? YES ���> NO [ )
��
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
QelJartmeni use only n
City of Northampton '
S _ oEE'er
.�
Building Department C e e t ,._ff g ^
_-
212 Main Street Sevrret�Sept►cAV ijal`ntmr
Room 100 WartCelJrratPabt4 ;
t Northamlpton, MA 01060 -
1_ Two Sets o€Strtrctura€
hone 41 -58740 Fax 413-587-1272 -
� x
P � floflS�fe
(. OtheC"Specify r r
APPLICAfiON TO CONSTRU T,ALT R,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECT—[ON-1
1.1 PropertwAddress: This.sectiotr to be complete by office
N[a tat
p Unit,
FY - 9,"7��� �d Zone Over a rDrstnct
L ErSf Distrtet
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
21 Owner of Record:
Current Mailing Address:
Telephone
elephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
_4 1 >7/:2---
ature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
EPIumbing (a)Building Permit Fee
al (b)Estimated Total Cost-of
Construction_from 6
g Building.Permit Fee
ical(HVAC)ection(1 +2+3+4+5) �� Check Number
This Section For OfficafUse Only
Building Permit Number Date'
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
_ b
BP-2008-0239
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-2008-0239
Project# JS-2008-000351
Est. Cost: $8834.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq. ft.): 9016.92 Owner: FENTON JOHN R JR&PATRICIA J
Zoning:URA Applicant: John Corbett
AT. 188 BRIDGE RD
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:91612007 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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 9/6/2007 0:00:00 $25.002672
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo