30A-078 Grity of Nazt4antptart
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DEPARTMENT OF BUILD0\1G INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '>a
Northampton, MA 01060 ,~ s
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as i:is/her construction sup,.: ,:nor. 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 backffll),
sonotube holes (before pour), a rough buildinL inspection (before work is
concealed). insulation inspection (if required) and a final 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 of Massachusetts
Department of Industrial Accidents
Office of Investigations
' a 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeEriblv
Name,Business/Organization/Individual):
T�i�
Address:
City/State/Zip: lgore,ti1,6 . 6,41;S 01062 Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.F-1 I am a employer with 4. [] I am a general contractor and I
mployees(full and/or part-time).
* have hired the sub-contractors 6. ❑New construction
;.�am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
hip and have no en�lo;�ees These sub-contractors have g, F-1 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.❑ 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.❑Roof repairs
insurance required] t _ c. 152, §1(4),and we have no
employees. [No workers'
1 Other
comp.insurance required.]
---"--".�ri}Tapp roan a c ec ox must a o r out a secnon a ow s owtn err wor ers'co -- "-
g mpensanon policy information.
t Homeowners who submit this affidavit indicating they aze doing all work and thrn hire outside contractors must submit a now affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors-have employees,they must provide their workers'comp.poficy 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$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 rti under the pains an enalties of p rjury that the information provided above is true and corre t
Si a e: / Date:Phone#:
Official 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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: j� Not Applicable ❑
Name of License Holder: �`fc���5 1 �� `t� C 2 cd.)22�2-"-
License Number
Address ((C�S f j Expiration Date
T
Signat elephone
9Re6istered t9om provement'•Contrector ;. -- - .-• �_. Not Applicable ❑
Comoa y Name Registration Number
Addr-e/1ss,, ,y / Expiration Date
Telephone/� le /
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...... ❑
I1. HomQaerI- e�nptzaa
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:Per n(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 tw amily dwelling,attached or detached structures accessory to such use and/or farm
structures.A verson who constructs re than one home in a two-vear period shall not be considered a homeowner.
Such"homeowner"shall submit to the Bui • g Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed un the buildinLy permit.
As acting Construction Supervisor your presence 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(Worker Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachus 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 pliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massa usetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement JMhdows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[O] Other[p]
Brief Description of Proposed{ � ���� IaJ° 5 U
Work: Recta-e) 1911 � 1 LG e X J
Alteration of existing bedroom Yes-4 No _ -Adding new-bedroom Yes e \ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
:Y- «c .:"za i �. »�.;3�""� ,�.:.,,-»�^ »mac-„'n�z,+c.•^. `m' �,ya„y' "� '.,�.t'a"`�-'. "�!.
sa_If New house and.orad°ditlon#a exls�rrt4�housing:..complete f`hfortov�inQ:
a. Use of building:One Family Icon Two Family Other
b. Number of rooms in each fa Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of uction. 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 construction es- - No
j. Depth of basement or cellar floor below finis ed grade
k. Will building conform to the Building and Zon g regulations? Yes No.
I. Septic Tank City Sewer rivate well City water Supply
SECTION 7a-OWNER.AUTHORIZATIOR-TQBE OMPLETED=WHEN
QWNERS'AGENT OR-CONTRACTORAPPLIES F BUILDING PERMIT
I, (
'4-e � (� l u i C as Owner of the subject
property 1
hereby authorize 1 I /�t ✓1%e `' S U
to act on my behalf, in all matt relative to work authorized by this building permit application.
r LZZ, 1112!Mn,14 1 9%®r-1i
Signature of Owner Date
ap_cw ffAjuthorized
Agent hereby da lare t -at 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 Na
ign re o O Date
~
_ ' /
�
Section 4. ZONING All Information-Must Be Completed,Permit Can Be Denied Due To Incomplete Information
Existi Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Varia nce/Fi riding ever been issued for/on the site?
- '
--' —'-- `~~ _ -----
S date issued:'
IF YES: Was the permit recorded at the Registry ofDeeds?
NO 0
IF YES: enter Book and/or Document#
B. Does the site contain a brook, body of water orwetlands? N DON7KNOVV 0 YES 0
IF YES, has permit been nr need to ba obtained from the Conservation Commission?
Needs tobeobta/oed �~� @hto�oed �~� Date
�~� v~� ' '
C. Do any signs exist un the property? YES K l NO �r
IF YES, describe size, type and location:
D. Are there _ hangestnoddonsos�nsin�endedforthopropo� ? YES NO
�
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing. g�di �g>over 1oc�or�dpo�ofe common p�n
that wW|d��rbover 1on�? YES NO
|F YES,then oNn�hom�onSmnn Water ManaQm6ent Permit from the DPW iorequired.
e rune
U E y qorthampton
U Bui1 i Departmentrrue eicut~ �:a
$�� s 2015 21!21 lain Streetisep va,a
f� om 100 e a ..
L-----.Northam ton, MA 01060 �; e_s
Electric Pnh r
phbiie 413-587-1240 Fax 413-587-1272 t?lo#rS f
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY.DWELLING
SECTION 1 -SITE INFORMATION
This sectron to be completed by office
1.1 Property Address:
e61 Map lot Unit
R( �t 1 f°c 1,14!,(�i`7 G Zane Overlajr Dratnct
Elm S 'mistnct - CB DistncY
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record: 1
Name Print Current Mailing Address: ^
('41 -z> Atw- a4A L-) Telephone
Signature
2.2 Authorized Agent: r /
Na nt) Current Mailing Address:
Gl/� 1 7�
ig ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION'COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building �`7 V 9C � _-(a)Building Permit Fee
2. Electrical 1/ (b)Estimated Total Cost"of
/ Construction from 6
3. Plumbing }< Building Permit Fee
r
4. Mechanical(HVAC) \�
5. Fire Protection
6. Total=0 +2+3+4+5) � Check Number
This Section For 6#16NIl'Use Ohl
Date
Building Permit Number Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
4 HIGH MEADOW RD BP-2016-0357
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30A-078 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit# BP-2016-0357
Project# JS-2016-000571
Est. Cost: $7000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SKYLINE DESIGN 002722
Lot Size(sq. 1): 89733.60 Owner: MURNANE JAMES A&ARLEEN E
zoning: URA(100)/WSP(100) Applicant: SKYLINE DESIGN
AT. 4 HIGH MEADOW RD
Applicant Address: Phone: Insurance:
P O Box 60142 (413) 586-8491
FLORENCEMA01062 ISSUED ON.911612015 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE SIDING & ONE REPLACEMENT
WINDOW
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 9/16/2015 0:00:00 $60.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner