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if *' 3001( •999. PAGE 19 HEIRS JF uLFRED AND MARY SPENCER 1
4
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 inspection process requires that the building department be called to
inspect work at various stages, which include foundation/footines (before backfill)
sonotube holes (before pour), a rough building inspection (before work is
11 • 1 , • 1 1 . • 1 1 • 1' .., 1 - ..i . 1 1 , 1 " 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
jermits 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
ii i
. .
. :
The Commonwealth of Massachusetts
• er*=.2.-----. Department of In dus Accidents
Office of Investigations .
600 Washington Street
• %-..e.if— Boston, MA 02111
, • ' www.mass gov/dia ....
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name pusineseorganizationfindivich.0:
Address: r -
City/State/Zip: . Phone.#:
Are you an employer? Check the appropriate box: Type of project (required): /
1.0 I am a employer with 4. El I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contactors 6. 0 New construction
listed on the attached sheet 7• 0 Remodeling
2. 4 I am a sole proprietor or partner-
These sub-contractors have
ship and have no employees 8. 0 Deinolidon
s '
working for me m any capacity. egrployee and have workers
9. 0 Buildink additicni
-
[No 'workers' corop. insurance
required.] - 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. 0 I am a homeowner doing all work officers have xercised their 11.0 Plumbing repairs or additions
myselL [No workers' comp. right of exemption per MGL 1-1... ..
12.0 Eno' repairs
insurance required.] t c. 152, §1(4), and we have no
or ,.
..4..,. .4 .... , c, •wO' ...#
camp- In suxance required.] -
*Any applicant that checks box #1 must also fill out the section below showing their worio:rs' compensation policy information. - -
t Homeowners who submit this affidaVit indicating they are doing all work and then hire outside contractors must submit anew 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 sub-contractom have employees, they must provide their workers comp. policy number.
lam 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-Ms. 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 Sectiar 25A 'OfMGL c 152 can lead to the irapOsitiOn of Ciimin:il penalties 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 5250.00 a day against the violator. Be advised That a copy of this statement may be forwarded to the Office of
H I N Y - ei ti ki ti o iis of the DIA for insurance coVeraie Viiffietitioii '7
_ I do here!, y _certifr under the pains and penaltiPs ofperjury that the information provided abov izje _andiorrpci
............... ,
.--
Signature: risk: 6 i it
Phone #: 4 f 2 --( t e(--in ( i
0. - .
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 ,IT pector 5. Plumbing Inspector
6. Other . fr.
Contact Person: Phone #:
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : r 1 L L- P ek- X v
u License Number
'31.-rkS 7 (.I\ F ot060 Z2-
Address Expiration Dat
y r2-
Signature Telephone
I} =Reriistere ClorriiiErripiten�ritltt" r4` -ZiaarE Not Applicable ❑
Company Name Registration Number
32- $ -ls 11f 1Zf tt
Address -}- /'- Expiration Da e
No 1 ci.vv, 1 Uv \ d t 0 60 Telephone¢) 7 Z,Vg421
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 Affe No ❑
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 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 State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors El
Accessory Bldg. fZI Demolition El New Signs [D] Decks [p Siding [DJ Other [0]
Brief Description of Proposed / /
Work: 8 K q w 0.5a '
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa tt> &Wil aiti — a l c xistiitai6iusii ql cr b i=tici faiaiivina:
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
GTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
;'OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I Z' y- i� , as Owner of the subject
property /
hereby authorize E_ Y^ I _. C • 1 0. "m
to act on m b alf • II matters relative to work aut by this building permit application.
r
Si to of a Date
I 'It'L� �� , as Owner /Authorized
Agent hereby declare thalt 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.
6 7„ r'e ci?LC d'i-e-' -
Print Name
��
ature o • : 1 - be 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
L ot Size .,gi9 j 1 t S e"1-' 1 g .°� _
Frontage "��i25 1 % ° ? i
Setbacks Front $ I / D 6 i €
Side L: 1 R:' i (LJThR:i�I.J I
Rear
L ! F
Building Height 0 1
I
Bldg. Square Footage = = % = i .t Z I
-`
Open Space Footag % -i
(Lot area minus bldg & paved i l , ..-
parking)
# of Parking Spaces
:.tip .3 j 1L ...,
Fill: r _
}
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Pag ? and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 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 0
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: 's
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.
9
e
City of Northampton
building Department -
212 Main Street
N 2 2 2010 Room 100 E
Northampton, MA 01060 r
phone 41,1 Fax 413 - 587 -1272
_APPLICATION1 O CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
This section to be completed by office
Property ' Address:
J,/ ' L f/ G- 1 Map Lot ' Unit
Zone Overlay Dist ct
orb s Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT
lei Owner of Record:
Name (Print) Current Mailing Address: / 3 S
,f .. Telephone ' —1
Signata ∎rp g „ --
2.2 Authorized Agent:
Y- ; L . i?a � y1 � 3 7- - 6 0 R-- r Pri (Zd o r o {,,s
Name (Print) Current Mailing Address:
2t9 42-A-40
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION' COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 3�aod (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 +4 +5) 360 Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File # BP- 2010 -1174
APPLICANT /CONTACT PERSON ERIC PAYNE
ADDRESS/PHONE 32 BURTS PIT RD NORTHAMPTON (413) 218 -4276 Q
PROPERTY LOCATION 5 BRATTON CT
MAP 17C PARCEL 201 001 ZONE GB000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out j a
Fee Paid
Typeof Construction: CONSTRUCT 8 X 9 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 086442
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO AVIATION 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
G 6 /2 C)
Signature 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.
5 BRATTON CT BP- 2010 -1174
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C - 201 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 -1174
Project # JS- 2010- 001710
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ERIC PAYNE 086442
— of Size sq. - }: - 1 0367:28 Owner :--- PALUMBO LISA M & GREGORY ERAMO
Zoning:GB(100)/ Applicant: ERIC PAYNE
- -- - Al ': 5 BRATTON CT
Applicant Address: Phone: Insurance:
32 BURTS PIT RD (413) 218 -4276 0
NORTHAMPTONMA01060 ISSUED ON:6/28/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK: CONSTRUCT 8 X 9 SHED
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: Fina;: (31 C ." ..-
______ THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES REGULATI 1 NS.
,11.°
Certificate of Occupanc -4°
del° sign ature: 490 . 4 1 . 4 8 /
FeeType: Date Paid: Amount:
Building 6/28/2010 0 :00 :00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
.._._ _ ...... _ ......_.