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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
- • • • L - • • • - • • • •rocess 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- i-n- conjunction.to_the_huilding 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, !
a understand the above.
(Ho • ; ow ,1 r /resident's signature requesting exemption)
I will call to sc edule all required building inspections necessary for the building permit
issued to me.
r �. Tofu `A A 1 ail Y 1
Address of work
location (� S
N RA Ile fkIA
41 ♦
The Commonwealth of Massachusetts
wy _ Department of Industrial Accidents
1 --:-. f Office of Investig,ations •
k ° ; 600 Washington Street
~
• --mar= hi
Boston, MA 02111
:.� . www.massgov /dia •
Workers' Compensation Insurance Affidavit: Builders/ Contractors [Electricians /Plumber
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: ,
City /State/Zip: Phone. #:
Are you an employer? Check the appropriate box: •Type of project (required): ",.
1. ❑ I am a employer with - 4.. ❑ I am a general contractor and I
employees (full and/or part- time).
have hired the sub- contractors 6. ❑New construction
2. El I am a sole proprietor or partner- listed on the attached sheet 7. [2
These sub - contractors have
ship 0 ,•
and have. no envioyees S. beriro, on
working for me in any capacity. employees and have workers' 9. Q Building addition
�'
co �nsuran e..
[No workers' comp. insurance 10.L j Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
3. . 1- am-a- homeowner doing-aIl- -work Oars have xezcised their 11 .. _ es . ing repairs or additions
myself o workers' co right of exemption per MGL
Y comp. 12. a Roof repairs
insurance required.) t c. 152, §1(4), and we have n o -
employees. [ N o w o r k e r s ' 13. ❑ O t h e r U rVbo di S z 06,..)k -
comp. insurance required./
*My applicant that checks box #1 m also fill out the section below showing their workers' compensation policy information.
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 attached 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.
Iam 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 -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 a fire
of up to $250.00 a day against the violator. 13e 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 certify under the pains and penalties of perjury that the information provided_above_is_true and_correct _ ___ •
Signature: Date:
-
Phone #:
Official use only. Do lint write vi 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. EIectrica1 Inspector 5. Plumbing Inspector _ ___
6. Other -
s.
Contact Person: Phone #:
i Al.,
I
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9: "Registered Home=linprovement Contractor fi .. i , N, ._ . < y -'' 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 ❑
'I :i U 11 a O ,.? V e k TI O1 t -
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.
J 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
1 ort ampton *Nina ces, a e - X ' • • - *, .I. _ " • •- G i tts6enera1. Laws - Annotated.
Homeowner Signature I// �' i
,/
i
A i ,
s
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
/
New House 0 Addition ❑ Replacement indows Alteration(s) ,8:1 R fang
Or Doors + /
Accessory Bldg. El Demolition CI New Signs [0] Decks [[f,] Siding [ ] Other [0]
Brief Description of Proposed
Work: C C)Y` e4-CI- 10 2l6 (knJ0VA NI
Alteration of existing bedroom Yes ) No Adding new bedroom Yes J` No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll - Sheet
ea, :If NeW ithAeF and of addition to existing houslnci; coml tete 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?
\ r d. Proposed Square footage of new construction. Dimensions
i i e. Number of stories?
r
f. Method of heating? Fireplaces or Woodstoves Number of each
, I 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
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, MAR-V\ � d . S ULL \U AA 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.
M fi�k4 S0LLiv
Print Name i, N 8 ,ofc,
1 it ,,,,,..,_
Signa
Own= gent Date
of 4
Section 4. ZONING Alt 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
Lot Size _____. _._ :.__, _..
Frontage _..
Setbacks Front
Side L :_ — . R::__ _._j L: L_____ir . ..__._> R:1._______
Rear
Building Height 1
Bldg. Square Footage ,- "°
Open Space Footage
(Lot area minus bldg & pavedI 1 m ,_?
parking)
# of Parking Spaces — `
Fill: ' 1 _.�..��.".�� - .n
(volume & Location) - — --< --M°" -.__— ___ "•-- -- -•- --. _ -,..
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW YES
, 7 9
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW � YES
IF YES: enter Book :; Pagel 1 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 , Date Issued
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
- -- D AF tf erfi a an ro osea c es to or a rtions o sighs inEe` edTor`t e ro Pe ? YES NO
YP P '; g P P Y ®)
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 9
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
11 *►
City of Northampton 5T�r,
Building Department �b vaymerr -
212 Main Street a4, v t 3 U u
g
Room 100 1 14u .0 0 f E
es,D�Q Northampton, MA 01060 1-,..06 v,..%,17.
- t aw ®- --,,,,,,;.,%.„,:'''.;2 a iik y ` V g n
� ,,\ \ , 'p h one 413- 587 -1240 Fax 413- 587 -1272 h ti i �' ��` l
p S® x � r t 4 " s
E
APPLICATION 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
1 _gyp _ , ._
r l�;1 Map Lot Unit
Zone Overlay District
EIm St' District CB - District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
J� tl L\V�A ,9,68° 36 f
Telephone
Signature
2.2 Authorize Agen
Name (Print) Current Mailing Address:
Signature Telephone
_
SECTION 3 - ESTIMATED C COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building l o / V c) u (a) Building °Permit Fee
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Fire Protection
S� (b) Estimated Total Cost of
i Construction from (6)
t � Building Permit Fee
Check i 0 O
�j
6. Total (1 + 2 + 3 + 4 + 5) ^ -= ? heck Number 1 7 1 ,97
� 7 3
is Section For official U se Only
Date
Building Permit Number: Issued:
--
Signature: �- X / /11'C6
Building Commissioner /Inspector of Buildings- Date
File # BP- 2010 -0657
APPLICANT /CONTACT PERSON SULLIVAN MARTIN J & KATHLEEN M
ADDRESS /PHONE FORT HILL RD HAYDENVILLE
PROPERTY LOCATION 12 WINTER ST
MAP 24D PARCEL 025 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 45'
Typeof Construction: COMPLETE INTERIOR RENOVATION
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
INFORMATION 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
s ...
/////0
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.
12 WINTER ST `' BP- 2010 -0657
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 025 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- 2010 -0657
Project # JS- 2010 - 000700
Est. Cost: $85500.00
Fee: $513.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:_ Homeowner as Contractor
Lot Size(sq. ft.): 5793.48 Owner: SULLIVAN MARTIN J & KATHLEEN M
Zoning: URB(100)/ Applicant: SULLIVAN MARTIN J & KATHLEEN M
AT: 12 WINTER ST
Applicant Address: Phone: Insurance:
I ° FORT HILL RD
HAYDENVILLEMA01039 ISSUED ON :1/11/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:COMPLETE INTERIOR RENOVATION
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Buitding Inspector
Underground: Service: Meter:
,,�;; Footings:
Rough:�`�- l `O( :R Rough: House # Foundation:
Driveway Final:
Final: 54 Final:
57)l /i) Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: 4-9.7-10, Oil: Insulation: a < f it la ''`O 015
f
� r
�
�1i
Final. '" � � : Smoke: � Final•
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND RE ;''
Certificate of Occupanc ature:
FeeType: Date Paid: Amount:
Building 1/11/2010 0:00:00 $513.00
• 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo