17D-015 E
A I
R E-XT-N -DTTO% ACKN0-W-LE C E ENT
E :
Tine State o-frMassachuset=ts allows the horrieown e.-Le right under 7SOC'NIR 108-3.4 to
!:Z, def4ine -HoineoW-ner" a�c, " '-erSo (S)
-tr construction S, S�La
act Lln� - L
Who owns a parcel on which he/she resides or intends to be, a one or two famizy
&.ve7ung, att,a ched or d,etache-,f structures accessory to such use and/or f,,-=, ==Lures. A
person Who Constructs More th=-, one home in a two-year period shall not be considered a
home owner.-
T-he ent, for the City of any per Who seek to
use the home-c-,mer examption, to act as their ow: cor-s'"L:11-02
that by doing so you become responsible for compliance with state building codes
ding artm.
and re-g-2ations-F -es that the building g dep ent be called
he inspec-tion process requires
to i:ispe--,woex at various stages, which include FolInd2tion/footings (before bacITUD.
so-Votube holes (before dour). a rough buRding hgsnection(before work is
cqvxe.ded�- (if required)
building these inspections re
de - wires failure to ections before the work is concealed, faUu
secure the.se inspections can result in failure to obtain a ccrdfcate of occupancv
umt-11-fie-W-G.Hk�-be-insut--ted-
If the h=eo7,ner hires other trades to perform woj14(--Ie--tncaL plumbing&gas) the
will be resuonsible to =-alce sure tlliatl-the trades hired secure their proper-
permits in ,;Zcton to the building per.ii,issued, and that get their
re ured
inspections.Failure of the individual trades to sec e the permits and inzpections as
requ-L-et-I can DEIAY the prc)j-,--L until such time as the proper permits and inspections are
made
im-derstand the above.
(Home owner Iresid.exi.Cs signature requesting exemption)
I will call to schedule all required building inspections necessary for the building Permit
issued to zie.
Date
Address-
location
_ ._ �epr;t,�aettt off."a datst;•ittl?ccide;ats
Of�fi�ce of Ini,estigations
- 600 J ash,'iz Wn Street
Boston, 3,14 02111
www.mass.g ow'dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A-_olicant Information Please Print Lealb;v
?dame (Business/Orsanization/Individual):
City;State/Zip: f�i �' �i�� Phone : ��� �.
Are you an employer? Check the appropriate box: Type of project(required):
4. ❑ I am a general contractor and I
1. I am a employer.with 6. ❑ New construction
employees (full and/or part-time). have hired the sub-contractors
1.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodelin2
ship and have no employees These sub-contractors have S. ❑ Demolition
workinLy for me in any capacity. employees and have workers'
P 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.,
re tired. 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
] officers have exercised their 11. Plumbing repairs or additions
�.❑ I am a homeowner doinLy all work a p
myself. [No workers' comp. right of exemption per MGL 12.7 Roof repairs
insurance required.] c. 1��, §1(,), and we have no
employees. [No workers' 1 ❑ 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.
=Cora,actors that check this box must attached an additional sheet showins 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: 15 / —
Policy r or Self-ins. Lic. #: 6v, S—y c3 >� / Expiration Date: /�//�
Job Site Address:
Z t(z 4o4141 c c City/State,/Zip: S
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 ofMGL 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 5250.00 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 terrify ii-rider-the-pains-anti penalties-of-perju-r-j that-the information provided above is trace and correct.
Sianature - j� ?= r - Date
Phone G<�
-aiciaLL1. DUot�vuteitalhis_area�_t�be completed city or towaz_off_aciaL
F v or Town: PermitiLicense#
ing Authority (circle one):
1. Board of Health ?. Building Department 3. CAF;/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
I 6. Other
:#.
Contact Persan: . hone -. �
i
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: / /2
/rf License Numberq t7�
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: " Not Applicable ❑
0147 I)J4 kv / -)i -C3 3
Company Name Registration Number
I �� :,1-i Sr c-/"
Address / Expiration Date
�� Telephone' `�7
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.E
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 pr 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 Local Zoning Laws and&44e of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement JuindoVs Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks Siding[❑] Other[❑]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes - No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes a----N o
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
Cai��iVl �ihor�as fl��,ie1 C�ri�te2
I , as Owner of the subject
property
hereby au horize
to act on behalf, in all matter elative to work authorized by this building permit application.
^\ 61
Signature of Owner Date
as Owner/Authorized
Age At 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 Lbe pains and penalties of perjury.
Print Name " f
Signature of Owner/Agent Date
f
Section 4. ZONING All Information Must Be Completed. 0ermit 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 _._.
parkin
#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 0
IF YES, date issued:',
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 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 0
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 0
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 0'
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
i
}
\` Department use only
City of Northampton Status of Permit:
,Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
r." Room`,100 WaterMell Availability
4. JVarthartptor�,-AAA 01060 Two Sets of Structural Plans
�. TO,one.413 2�5iiL�40 Fax 413-587-1272 Plot/SitePlans
Other;Specify.'
AAPCTI;ATION 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:
7i derorwa i`r oCt Map Lot Unit
�to ren ce Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
f 2.1 Owner of Record:
ca►�liA
N (P Current Mailing Address:
*� Telephone
Signature
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 (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+ Check Number
This Section For Official Use Only
Date
Building Permit Number: issued:
Signature:
- n---"- - -----------
Building Commissioner/Inspector ofBw ingid"s---' Date
BP-2008-0746
GIS#: COMMONWEALTH OF MASSACHUSETTS
I 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-2008-0746
Project# JS-2008-001161
Est.Cost: $9000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Roy Omasta 101533
Lot Size(sq. ft.): 12588.84 Owner: THOMAS CAITLIN&DANIEL GOMEZ
Zoning. URB Applicant: Roy Omasta
AT. 11 VERONA ST
Applicant Address: Phone: Insurance:
21 North St (413) 247-5666 Workers Compensation
HATFIELDMA01038 ISSUED ON:31512008 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 3/5/2008 0:00:00 $25.0019181
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo