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Figure C5. Example of Typical Deck Framing Plan
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 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 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 person(s) who seek to use
the home owner exemption, ° 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 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
iermits 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, C 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 C1 I t i ('lA (
Address of work
location ,2% g KA
E f , 444- 0 l® (rrt_-
...
The Commonwealth of Massachusetts
Department ofindustrial Accidents
. = 4 1 . 4 .... ..-. . Office of Investigations . .
600 Washington Street
: 74 1E— Z Boston, MA 02111
•
1.,.....„
ov/dia www.mass o
-r,
-Workers' Compensation Insurance Affidavit Builders/Con _
Applicant Information - Please Print Legibly • ::
Name alusines.i/Orguniiationandivichial): L- (;C A 5 - - r \. cA1(2_,
: -
- Address: (z.,q ( Q B vA P 9 -e_ r?_AN ; .
. /..., - 13 3 z_ oq_s___
0 /91,4 6 '
Phone.#:
City/State/Zip: fQii L
._ . -. 1
Are you an employer? Check the appropriate box: Type of Pi -oject (required): 11"
1. 0 I a employer ' . 4. 0 I am a general contractor and I
6. 0 New coistriietion.
employees (full and/or part-time). * have hired the sub-contractors
Th list:d on thesaMached sheet. 7. 0 Remodeling .
2.0 I arn a sole proprietor or partner-
These sub-contractors hav
ship' and have Iil ::loyees -8. 0 DeMblition.
• working forme in any capacity . eggioyees,andhave workers'
9: 1:1Bilildieg'adition
[No werke?s' comp. insaiance - con -
Kfran!cr-1 ' : • m a homeowner dOing ill work o 5. 0 We are a corpot-ation and its 10.0 Electrical repairs or additions
3. lam hai7e4xercised their . 11. PluMbing repairs or additions
myself [No workers' comp. - right of exemption per MGL r-r ,, ,-
12.L j ADOI repairs
insurance required.] t • . 152, §1(4), and we have no 1 ,..,, , , • v i)
employees: [No workers' 13.4.1 Other lit ^ 4 4 i K
,
. . comp- insurance retitii:ted-J- tA°.fitaCe - .datfliaptal rtt de._
*My applicant that checks box nmust also fill out the section below -showing their workers compensation policy infonxistion;
t Homeownera who submit this affadaVit.incricating they are doing all work and then hire outside aontiadors must submit anew affidavit indicating such
:contractors that check this box must attached an additional sheet showing the name of the subcontractors and State vtether or not those entities have
employees. If the sub-contraitorsbmie employed, they must provide . their wciricers' comp. policy nmnber. . : , : -- • •
lam an employer that is providing workers' compensation insurance for my employees. Below th:policyOndjob site
information.
. -
Insurance Company Name: •
. • . . . -
Policy # or Self-ini. Lic. #: - Expiration Date: - • ,
Job Site Address: : - City/State/Z,ip:'
' Attach a copy of the workers' compensation policy declaration page (sh the pplicy number and expiration date).
_ „ . _ . . - -__
. . .
Failure to secure coverage as reqnitid'iMkleir Seetroil 152cFah. lead to the imposition of. - riii:11I141 iiiiitaiiieS of a
fine 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 S250.00 a day against the violator'. Be advised that a copy of this statement may be forwarded to the.Oi:6ielof
Inveiriiiiiiiis ' '' 7 -- - -7. -- 7. ------- '77:77:= 4 : — 77, 1
_
1r6r. :4; te p --- " --- an 11 p ;!X rildeii€73:1; li;;iittri iltiinfirMtiti;j;iiiil..i4iiiiagivrizeWorrerT .. .:
. .
Si (i i -...„ .
anantre : ../-■.._ . , - ' . Date: i 1 ' ( 1 : ,
Phone ii: t 3 5 6 41--,: .: ' .. . " . - _ • • .
•
I . - Official use only. Do not write in this area, to be completed by City a r toW nOfficiaL
City or Town: -
Issuing Authority (circle one):
.- Permit/License #
..1. 6.Other Health d of Heal 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.th
Contact Person:
Phone #:
•
t
SECTION 8 -- CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9 ;Ftiokatere r.ltPiti "linarovenieiiii o ra onatZa i ~' r' ` Not Applicable ❑
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 ❑
��� qtr« + ` ¢ Y :j AW
i1: 4*, me °'' s � u 13;
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 an 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 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 apd Loc 1 ning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature ..j\--..--,....._
F
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [] Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. El Demolition ❑ New Signs [D] Decks [[k Siding [D] Other [D]
Brief Description of Propose.
Work: `, �, t ►v � � � cc� i ' , cj
rQ � �` � _ r` � i l r `
Alteration of existing bedroom r Yes No Adding new bedroom Yes No
Attached Narrative Renov ing unfinished basement Yes No
y
Plans Attached Roll - Sheet - )(Gtte_ rick iO cep LA f1 g
a if +te i6ii nit Fattli iiffff " ifadk sing oriapiefe' th4 fcitavi tfq:
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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1.) , 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 L- (S --S r (A! , 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.
L —e---
Print
V�-=- 4(t -(wI
Signature of Owner /Agent Date
s
1
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
�r 4 J K. This column to be filld in by
/ Building Department
i
Lot Size I
Frontage
Setbacks Front i " ""-
Side L: R:' L: .. R: t
Rear = 1
Building Height € J s
Bldg. Square Footage i 77 % " --" 1] I
Open Space Footage %
(Lot area minus bldg & paved w '
parking)
# of Parking Spaces I ~-
Fill:
(volume & Location) t
A. Has a Special Permit /Variance /Fi •i over been issued for /on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:I
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES Q
IF YES: enter Book � Pagel and /or Document ft= �. ---
B. Does the site contain a brook, body of water or wetlands? NO +, DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained Q , Date Issued: (
C. Do any signs exist on the property? YES Q NO !if
IF YES, describe size, type and location: 1 �___..._.__x.._.._..4
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO es
IF YES, describe size, type and location: S _
E. Will the construction activity disturb (clearing, gradin• ex vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO e �
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
1. c 4 ±
City of Northampton .,
L-
Building Department � _ ;' `
212 Main Street
Room 100
r ,, .,
A
BPD 13 4L/It Northampton, MA 01060
• one 13- 587 -1240 Fax 413 - 587 -1272 ffi
^ J.OF 6UUD�NG wisp!, ' t d a A N % 'Y , l It w i'' , '
• A FL P L 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
I li Q iz.t ) -, 12.9 Map Lot Unit
P l t( c ((11(1,A 0(0(01-- Zone Overlay District
�
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
L. ( EA s L,J R--- Ja4ri --e
Name (Print) Current Mailing Address: ei / ,( 56 , 2._ o4S2o
�- 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 permit applicant
1. Building „ j 70 0 , ,i (a) Building Permit Fee
2. Electrical (.,0 A --- (b) Estimated Total Cost of
Construction from (6)
3. Plumbing r4 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3+4 +5) \ l- e Check Number / 3 O Cj
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
t-
s �
•
File # BP -2011 -0828 \NV c rO tyofri
APPLICANT /CONTACT PERSON STOWE LISA A oty7 - ( eiA/
ADDRESS/PHONE 296 BRIDGE RD FLORENCE (413) 582 -0452 0
PROPERTY LOCATION 296 BRIDGE RD
MAP 17A PARCEL 089 001 ZONE URA(100) / /RI 11 f
L; THIS SECTION FOR OFFICIAL USE ONLY: ��✓
PERMIT APPLICATION CHECKLIST
) ENCLOSED REQUIRED DATE JtA"
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid /4)6
Typeof Construction: REPLACED DAMAGED DECK,& REPAIR DAMAGED CEILING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION PRESENTED:
V Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER: §
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
Demolition Delay
W f• CLAPS./ I Zv i(
4:n ture of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
1
•
296 BRIDGE RD BP- 2011 -0828
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 089 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2011 -0828
Project # JS- 2011- 001364
Est. Cost: $7200.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 12458.16 Owner: STOWE LISA A
Zoning: URA(100) //RI Applicant: STOWE LISA A
AT: 296 BRIDGE RD
Applicant Address: Phone: Insurance:
296 BRIDGE RD (413) 582 -0452 0
FLORENCEMA01062 ISSUED ON:4/26/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACED DAMAGED DECK(SAME
FOOTPRINT),& REPAIR DAMAGED CEILING
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 4/26/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner