17A-242 4
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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, 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 inspectinx piaEess 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
- - - - -- per -nits- in- conjunction_to- the_ building _permit_issued,_and_ 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.
ate
Address of work
location
` ,\ The Commonwealth of Massachusetts
__ -'-- Department of Industrial Accidents
1 =Re
Office of Investigations •
• iu .� 600 W ashington Street
t Boston, MA 02111
.,•'' www.mass.gov /dia
-Workers' Compensation Insurance davit: Builders/ Contractors /Electricians/Plumb.ers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): r �
Address: �b # - r ,
ice
City /State/Zip:.�r'f ,/�� Ji i P ho ne.: �3S '�' 7/7
Are ou an employer? Check the appropriate box:
y Type of project (requited ): /
1.0 I am a mployer with 4. 0 I am a general contractor and I 6. 1,w
ogees (full and /orpart- time). * have hired the sub- contractors
2. I am a sole proprietor or partner- listed on the attached sheet 7. 2Remodeling
ship and have no. employees These sub - contractors have. 8. 0 Deruol on
for in an aci employees and have workers'
working y capacity. 9. ❑ Building addition
[No workers' comp insurance comp_ insurance .t
required:] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. [l I am -all wo rk _o c__enss_ ave is_ed their --1-1-- - P.lurnbing repairs or additions
myself [No workers' comp. right of exemption 'per MGL
12.0 2oof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13. Other CX. _
comp- insurance required,]
*Any applicant that checks box #1 must also fin out the section below showing their workers' compensation policy infomtation. ,
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 .artarhed 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 my employees. Below is the policy and job site
formation.
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 afi
of up to $250.00 a day against the violator. "1$e advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverat= erification
I do hereby certify under the pains and p ' ; s of pedury `that the information provided_abov _ ' , e_ indcorrect — - ..-
i
Si. a - tore: _//. ir..�►�®—M s . 0
Phone #: / // 3-- 71
Official use only Do not write ti this area, to be completed 5y city or town offie at
City or Town: Permit/License #
Issuing Authority (circle one):
f. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other —
Contact Person: Phone #: :
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : emcz /� 6 p
License Number / 9
17 - 57 1/ 0/0
Address Expiration Date ///:/5 7:1-'11,23 re Tele one P
9. Registered Home l® ti ®vementContra or , ::. , r _. _'y y .s ..; .w" Not Applicable ❑
e 1 ! M .G 1/ ?9' 7 •
Company me . Registration Num er
/ 20 / .th. 1 22 /6/
Address Expiration a e
' e ' e ? , %,/ S 10- Telephone/ .e,/ ' 53(1/7
_ _ 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 buildin "permit.
Signed Affidavit Attached Yes No ❑
_ _ The_current_exemption for `homeowners" was extended to include Owner 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 1083.5.1.
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 building permit.
As acting Construction Supervisur yuut presence on the job site will be required from time to time, during and npnn
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
__ - ---- ®o ampton • r • mances, - • . • i , ., , . - tts - General- Laws- Annotated. -
Homcowner Signature
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I SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement�dows Alteration(s) ❑ Roofing ❑
Or boors
Accessory Bldg. Demolition ❑ New Signs [D] Decks [l Siding [1:,7.11 Other [O)
0' c' � ® ► r 01 t P N 0 e7 iS T l/ t). 4 VC' 0 19 - A4'cr '
Brief D- cription of Proposed J
Work: a . . • -- -;t :. , — at _ f -, it ii.: ` r ► . a 6)/P/ Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes " ' No /�
Attached Narrative Renovating unfinished basement Yes jr No
Plans Attached Roll - Sheet
sa ; !f Miew S ous eland ,iii a; rteon to "exist[ "nq ho . com tFie -fc�I 1 g.
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
-- : , as Owner of the subject
i property
� i ct
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, e 1 F rj TJ ,� , as Owner /Authorized
Agent hereby declare hat tl a statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the ury. p in and penalties of p
7 J71/7 7
Print Name
✓'
- ,./.r 1 .t r. /r $ d- - - —
Signature of Own: • Date
.✓
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Proposed Required by Zoning
i Ax i igte„,,,i
i* This column to be filled in by
( Building Department
Lot Size �_..,_ __..1.. �� �. o.. ._._. L___—_—_—___..,„..,_ ,
Frontage ?7 ,- Lc .-- Z 5-------,: ' �
Setbacks Front
Side L.. u R. ? .. L:u.. _. R •,
Rear / � f ,..
Building Height i
Bldg. Square Footage ,. % _` `.._.._._.
Open Space Footage
(Lot area minus bldg & paved t „ �_ .
parking)
# of Parking Spaces — -- _---°
Fill: K— ;
(volume & Location) _ w.__�_.„... ,.._._ ._......._. µ, ._..w_ __. ___
A. Has a Spe al Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page; i and /or Document #,
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date issued
C. Do any signs exist on the property? YES 0 NO er
IF YES, describe size, type and location: r
------ -- -n - - =- rm? t a�a aTrj — rri` 65753 c - arises _o or a _ 1t on5 si ns in Pn Qr ni YIiP rn rt 7 YFS 0 NO
yP R -._ c or o 8 P f� y
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excav ' , or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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City of Northampton St�ao�extti�
Building Department Ctittatvay�et r
212 Main Street Sw+��itdlvatbt 3k �s
Room 100*
Northampton, MA 01060 ,roto
phone 413 -587 -1240 Fax 413- 587 -1272 14 �'# ., °�
1 � `Spe�t�y
APPLICATION 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:
7 2 ZiVE- Map Lot Unit
7,4,L l %V(z" d4- `Zone Overlay District
' EIm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Ofner of Record: 7 heer
" l4 7- —1 Name (Print) Current Mailing Address:
Telephone
Signature 01030
2.2 Authorized • • ent:
fir C Jr iT" 0 7 1 1(1 rn1 5 4- AA / S
Name (Print) Current Mailing Address:
... .r►'.. =!� /1 /_ 33r
Signature Telephone
SECTI • 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building /7 C . ( 2 1 •(a) Building Permit Fee
2. Electrical / Gj • `;, (b) Estimated Total Cost of
• Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) -
5. Fire Protection � C U Check Number �
6. Total 1 + 2 + 3 + 4 + 5) 2eck Number
This Section For Official Use Onty
Date
Building Permit Number: Issued:
Signature
Building Commissioner /Inspector of Baitdings T Date
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File # BP- 2010 -0597
APPLICANT /CONTACT PERSON JEFFREY E SMITH
ADDRESS/PHONE 207 NORTHWEST ST FEEDING HILLS (413) 335 -3717
PROPERTY LOCATION 72 LAKE ST
MAP 17A PARCEL 242 001 ZONE URB(100j/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 7P C4080
Typeof Construction: CONSTRUCT 12 X 25 DECK TO DET GARAGE & CONVERT GARAGE TO
WORKOUT GYM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 083719
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
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
��2 /el
g
Sig ature 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.
V.
ir, t BP- 2010 -0597
uis 4: 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- 2010 -0597
Project # JS- 2010- 000869
Est. Cost: $22000.00
Fee: $132.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JEFFREY E SMITH 083719
Lot Size(sq. ft.): 16160.76 Owner: LANGLAIS LINDA A
Zoning URB(100)/ Applicant: JEFFREY E SMITH
AT: 72 LAKE ST
Applicant Address: Phone: Insurance:
207 NORTHWEST ST (413) 335 -3717
FEEDING HILLSMA01030 ISSUED ON:12/22/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 12 X 25 DECK TO DET GARAGE
& CONVERT GARAGE TO WORKOUT GYM
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 12/22/2009 0:00:00 $132.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
72 LAKE ST BP -2 01Q 0597
Gls #: CO M MONWEA LT H OF MAS T � £
Nla :Block 17A - 242 CITY OF NOR 4'.';'-`-' ..
Lot: -001
PE CONTR WITH UNREGISTERED CONTRA -
Permit: Buildin DO NOT H A CC E SS T O THE GU ARAN TY • FU (MGL C.,- 1 4 2A .
Categor
B U Ij DING P EA S.
Permit# B P - 201 -05 t 2 %.
Pro j e ct t JS- 201 - 00 0869 . : 7 '
Es Cost $22000.00 .
Fee $1 32.00 PE RMISSI ON IS H EREB Y G :TO: .
Cons Class: Contractor Licen � t l f =`
Use Group JEFFR E SMITH 08 3 719 ` ` •
Lot Size( ft.): 1 6160. 7 6 O wner: LANGL LINDA A
on in : rltBt l o�)/ Appl icant: JEFF E S MIT E —
A T: 72 LA ST
App l i c ant Ad dress: Pho ne: In nc. '�-
207 NORTH S T (4 33 -3 7 1 7
FEED' HILLSMA0 ISSUED 01V:12/22/20 0:0,,°- _, ..
TO PE R FORM THE F 12 X 2 DECK T O DE` G - Est i £x
& CONVERT G A RA G E TO WO RKOUT GY
as ,t -y" ' ' , :
POST THIS CA SO IT I VISI BLE FROM THE STREET .
Inspector of Plu mbing Ins p e ctor of W irin D Building-1 nspec -
Underground: Service:. Meter EI
. I at .'u..,. p
Footings n• : f , � � �.'
Rough: Rough ,,, House l me Fo undati o
Driveway Fina
Final:
Final:
d I///° r
49 Rough Fra , K ::: r.-4
Gas: F ire Departmen Fireplace / hitnl�ey: r '
��:sga:
coil' Ins ulation: t _ 4 .
-t - t �
Final: Smoke: Final
THIS PE RM IT M AY BE REVO BY THE CIT OF NORTHAMPTO U PO N V I O L ATION O
ANY OF ITS RULES AN REGULAT � "
Certificate o Occu • anc �. S - �
Fee Type: Da te Pai d: Amount {
Building 12122/ -2009 0:00:00 $13 r � }
212 Main Street Phone (413) 58 -1240 F ax: ( 413 587 - 1272 ,_ F ,` ' " `
f y rro CY34"4Y =Y�^+Y/C' .a
Building Commissioner - Anthony Patillo �k . .
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