29-491 City of Northampton
Massachusetts 4
DEPARTMENT OF BUILDING INSPECTIONS r :
w , 212 Main Street • Municipal Building � L ,
' "e Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 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 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 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, ; CJ � - - understand the above.
( H o A , Gy . me owner resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date 4f//L 1 -
Address of work location y6 2 12yA/ /'/,
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The Commonwealth afMassachusetts
,, ` k_ . Department oflndustrial Accidents
"M �= = r Office oftnvestfgatio►rs
1/4416.. :. r yYashington Street
Bositon,111A 021).1 _ ' www.mass.gonl/die
Workers' Compensation insurance Affidavit: Builders/ Contr actors/Electricians/Plnmbera
,AnDlicant information Please Print f..esgibly
Name( 'vidual): V►a11M Ml''?EIe
Address: /7 ..... Iv ,e .. . .. —
City /State/Zip: `L e E Ir MCI o/D'G 2., loon #: s-, ''1-rd-r9
Are you 9n employer? Check the appropriate box: Type of project (required):
1.0 i am a employer with 4. ❑ I am a general contractor and I 6. L mew construction
employees (full and/or part-time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet: t 7. 0 Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. 0 Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
olequired.] officers have exercised their 10.0 Electrical repairs or additions 1
3. Le I am a homeowner doing all work right of exemption per Mt3L 11.0 Plumbing repairs or additions 1
myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.]
I3.❑ Other
•Any applicant that checks bat ill must also till out the section below showing their workers' compensative policy information.
t Homeowners who submit this affidavit indicating they arc doing Ail work and than him outside contactors must submit a now affidavit indicating arch.
;Contractors that check this box must attached an additional sheet slurring tdc name of the sub-contractors and Their workers' comp. policy information.
I am :providing an employer that k workers' c Insurance for my employees Below is the policy acrd, fob site
information.
Insurance Company Name: –.— _ -
Policy # or Self -ins. Lic. #: Expiration Date: . -
Job Site Address:_ City/State/Zip:
Attach a copy of the workers' compensadon policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year impriaomnent, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the viola. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for Insurance coverage verification.
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1 do kph* .1' under its pains a nd penalties ofperfury that f' he lip arr ►ion provided above is true and comet --- Signature: el a .1 ` 4.rce. - Date: 21 Alice ! se
Phone #: .. _ -- .
I Official use only. Do not write in this area, to be completed by city or town official,
i
City or Town: , _ Permit/l.,icense # __ .. _ _ _ _
Issuing Authority (circle one):
I
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
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SECTION 8 - CONSTRUCTION SERVICE$
8.1 peened Construction Supervisor: Not Applicable CI
Name of License Holder
Linens* Number
Addre& v _ Expiation Date
Signature Telephone
8: Rest�tered.hiorttes
tDt+oveme►1t Contiaact3dC ;• , , . .. ' .. Not Applicable ❑
ddlISM nv Name Registration Number
Address -- Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this davit wiif result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes. 0 No. 0
11. oioae C .ne r ac�i tut on[
The current exemption fbr "homeowners" was extended to include fir oeeostie,d ly__0_ng 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 tbat the owner acts
ss auneryiwr. C1Mr Sec�ia►198
W Ronteowner: 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 struc:iures accessory to such use and/ or farm
structures. A oerson who co tracts more than one home ioA two -nar period shall not be cjaideredgpo weer.
Such "homeowner" shall submit to the Building Official, on a form amble to the Building Official, that betake shall be
responsible for all such work aerfarwed under the build* permit,
As acting CIMMDICAMLNEnnlifdtr your presence on the Job site will be required nom time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that wlth reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability ofEmployers to
Employees fbr injarirss not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for persons)
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 ,
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SECTION 5- DEfiCREPTION OF PROPOSED WORK(chack all applicable)
New House jJ Addition 0 Replacement Windows Alteration(s) 0 Roofing Q
,-,�(� Or Doors
Accessory Bldg. L.�'J Demoltttan ❑ New Signs MX Decks [CI Siding 0:II Other [C1
Brief Description of proposed /)( 3 0
Work: CONr T' PCT - /GA/ r�� �,a
G A /eh
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached toll - Sheet
aa; it New ho . :......
ut�Q..atid`or`actditioii iii:ixisti'Eia : tioewlna iiiimalete:;foliowlriq -
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 constriction_ __ 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. WM building conform to the Building and Zoning regulations? Yes No .
1 Septic Tank City Sewer .r-- Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION . TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , 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.
nahne of Owner Date - �—
I, — _ i t / / r elm L AMA go-, . 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 at perjury.
IA/ / L 1 '-»m 4-A►- 1.1#P
Part Name
G... .,, . 13 ,1i 9 Y' / A
Signature of OwnerlAgent Date
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Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zing
This column tu be filled in by
Building Department
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Lot Si '4 /Idl 1" ---------------- 1 i -IMMEMI
I
Frontage L___
Setbacks Front
L E1 i
Side L:1-----.1 R:t . . --1 1.,:al R:1 J 1 ---- 1
Ent 1 11 1...........i
Building Height = . tiii2,1
Bldg. Square Footage
L___J L__J 14 1 1 L171 --
L....ii
Open Space Footage
Lot area minus bldg & paved .1 -....- ‘ ... 1 1 r{ C ---- 1 1 ---- 1 L(55 1
' I • i
, . n ‘
0 ofParkin: S , aces r ---]
Fill: 1
(volume & L. 1'1 1
_...
A. Has a Specjat Perrnit/Variance/Finding ever been issued for/on the site?
.---- NO DONT KNOW 0 YES
IF YES, date issued:I J
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 1 YES 0
IF YES: enter Book I i Pagel_ :1 and/or Docent ft
_......._
B. Does the site contain a brook, body of water or wettands? NO er DONT KNOW 0 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: 1 ,..
t ______ ... _ ........
--di. C. Do any signs exist on the property? YES 0 NO er
IF YES, describe size, type and location: L 1
....._ ... .... _ ......... . ,...
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: I __......._.............,........._____
.......... E. MI the construction activity disturb (deering, EPEdin9glation or filling) over 1 acre or is it pert of a common plan
that will disturb over 1 acre? YES 0 N
IF YES. then a Northampton Storm Water Management Permit from the DPW Is rewind
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CE1VED
G Ity of Northampton
Building Department //•(u� : R `n e P �. f
VU• �•.C'I{�v..[f ��.RY7 ,"• ":'�...'y :. �;::^S• ..:..ai'�.:t(�fi +.:fi.•JY:
mi 2 7 201a 212 Main Street 3tYte}iir ?Avdilatiity ' _,,� E > F' .
Room 100
.��N!7,'r '.' " •` viva -. :t ^' +.
orthampton, MA 01080 sets ? atsiwcrur► €F'li�ris -"' :;a •;.� °; ^,:i;a
T. OF BUILDING _
DEPT.
e 8 7 -1240
4 i58 t?lot�8`iteieiis :'<-" z.:
VLT1 `' ..�,Y.+ :::'st.:; ^`'.�:o: <::•.•::�
I APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE IPFORMATION
1.1 Property Address:
Thie section to be cowl/eked b j
11 40? e y hiv re D Map Lot
FL O NG ` Zone owriar Distnc#
Elm St DIsMcR CB District '
SECTION 2 - PROPERTY OWNERSHIP /AUTHORED AGENT
2.i Owner of Record:
WILLIAM L I4 t1 & ee Yd" 9 it i N /2,i7 Pfd 'ANL°E
Name (Prird Current Mailing Address:
trig- , P
1T, - Telephone
signature
2.2 Authorized Arrant:
Narne (Print) Current Marling Address:
Signature Telephone — —
SECTION 3 - ESTIMATED CONSTRUCTION COSTS 1
item Estimated Cast (Dollars) to be I Official Use Only
completed by permit applicant
r-- 1 Buiding p 19J &A7/ON r q (a) Building Permit Fee
+
2. Electrical tom) ir.sermiked RAS Cedtdi
Construction from 13)
3. Plumbing Bunclin9 Permit Fee
4. Mechanical (IIVAC)
#i. Fire Protection $10 �� 6. Total (1 + 2 '+' 3 + 4 + 5) Check Number This Secti n F Onl�r -
m tt%
Budding Permit Number. I Issued:
Signature: _2L�
Sul4ng Commissioner/Inspector of Buildings -- - pate
iose
457 RYAN RD BP- 2012 -0875
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 491 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: FOUNDATION BUILDING PERMIT
Permit # BP- 2012 -0875
Project # JS- 2012- 001535
Est. Cost: $5929.00
Fee: $108.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 19994.04 Owner: LAMERE WILLIAM C & PATRICIA A
Zoning: Applicant: LAMERE WILLIAM C & PATRICIA A
AT: 457 RYAN RD
Applicant Address: Phone: Insurance:
457 RYAN RD (413)584 -15890
FLORENCEMA01062 ISSUED ON:4/9/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: FOUNDATION ONLY FOR 18 X 30 GARAGE
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 4/9/2012 0:00:00 $108.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner