29-206 1
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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 ofNorthampton 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 inspectio u 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 -in conjun. ction.to the building_ ennit issued,_ 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 • ption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Address of work
location
• The Commonwealth of Massachusetts
Department of Industrial Accidents
_ 1 L — ' Office of Investigations •
— ' ta 600 Washington Street
Boston, MA 02111
www.massgov /dia
mg
-Workers' Compensation Insurance Affidavit: Builders /Contrac tors /Electricians /Plumbers
Applicant Information Please Print Leo
Name (Business /organization/Individual):
Address: .
City /State /Zip: Phone. #:
Are you an employer? Check the appropriate box: Type of project (required): i'
1. I am a employer with 4.. 0 I am a general contractor and I 6. 0 New 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. 7. 0 Remodeling
ship and have. no Psloyees These sub - contractors have 8. 0 Demolon
Io ees - and have workers'
working for me in any capacity. Y 9. 0 Building addition
[No workers' comp. insurance . comp. insurance-
required.] 5. 0 W are a corporation and its 10.0 Electrical repairs or additions
3 I am a�emeowner d � all worlt o cer Ilav� xerc cl heir 11-4 P'lv£ahing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required] t c. 152, § 1(4), and we have no .
employees. [No workers' 13.0 Other
comp. insurance required} 1
"Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information-
t Homeowners who submit this affcdavit. indicating they are doing all work and then hire outside contractors most 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.
I 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- -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 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 fiTh.:
of up to $250.00 a day against the violator. i5 e advised that a copy of this statement may be forwarded to the Office of
Investigations of the IDIA for insurance coverage verification
f
I do ape certi u •., the • ,.: and p n ofpe 'ury that the ormation provided_ab / ve_' rue axuLcorrect.____ _
t .. tore: �'� A-46- - _ f ate. i J L ."'�
Phone #: 1 'fi► •
mot:
- Official use only. Do not WTIte iii this area, ii be compered by city or town offiddaL
C ity or Town: P #__
Issuing Authority (circle one):
I: Board of f ea1th 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbinr* Inspector
6. Other .
Contact Person: Phone #: -
AMP
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telep "e
9:,Rectistered- Homelirmrovemen eMtbic' ,.,.... Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GL. 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 ❑
�"°, F " x ° mo r# is
The_current_exemption for "homeoovners" 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 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 . or yoi .. this -emit.
The undersigned "homeo er" certi `-s and ass. es r:sponsibili or comp 'ante with . e State Building Code, City of
Northampton )rdiTanWS7: ` ._ia re ", - s- Gener. -Laws-Annotated.
,1111 Mir
Homeowner Signature
1 ilk
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition [1 Replacement Windows Alteration(s) ❑ Roofing J
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[l Siding [CI] Other [O]
Brief Descri n of Proposed
Work: ,A,'C'N 1.- Ill ejll i I1� ?^'g f l �,� —
Alteration of existing bedroom Yes No 1 Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a_ `If .N fiause ,a #1 to existma housingec h1plete th foI1oW
a. Use of building : One Family ' Two Family Other
b. Number of rooms in each family unit: V Number of Bathrooms
c. Is there a garage attached ? /JO
d. Proposed Square footage of new construction. Dimensions
O r
e. Number of stories? 1
f. Method of heating? L\ t (; Lry,7)/ _ (AFireplaces or Woodstoves 4}�> 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 f 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
IC 0 S. ' 6
I, %YAM* , as Owner of the subject
property
hereby - thori e
to act • y behalf, in a '•a -rs relative N work auth• ' ed • this building permit application.
,,
Signatu - of Owner Date s(JAr„
I , 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.
Print Name
Signature of Owner /Agent Date
+F.
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
Lot Size
Frontage
Setbacks Front
Side L. R
Rear
Building Height
Bldg. Square Footage % „,
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill: it
(volume & Location) ( .
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 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 0
IF YES: enter Book ` Page and /or Document #
B. Does the site contain a brook, body wa or ttands? NO 40 DONT KNOW 0 YES
IF YES, has a permit been or n to obt fined from the Conservation Commission?
Needs to be obtained 0 fined 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
"D — Are there'any proposed "changes fo or ad tiin`s gns intended for the property ? YES 0 NO
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 Cp
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
■
NF3iparttient'ise cif `'
City of Northampton Sad to - . E k *
Building Department Ctiii D nyeuuay Ferlt w r
212 Main Street ,5 a rtc adabrl� ° - =� Q v,
Room 100 yar n ,,, L 14
Northampton, MA 01060 , � ra N ' ; a
phone 413- 587 -1240 Fax 413- 587 -1272 , e la , AW t t r 4p
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 office
// 2.1 i e. b i-, Map ' Lot Unit
r tO (`e c / ill A 010 6 Zo Overlay District
Elm St' District GB: District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
- - - 01/9 -1,J;(16-ki,-444_ ________ _ _i_j_ __,Bes..4_4,'-e_ - r, 1-741-7046-p, Milg(06),
Name (Print) Current Mailing Address:
1 1/3 - 5 - 1CIP —C, fs it;5
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 e2 0 . ®o (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Op, U t) Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) . OP.. 0 Check Number
This Section For Official USe O nly
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of-Buildings Date
Lil
File # BP- 2010 -0387
APPLICANT /CONTACT PERSON WICHOWSKI THOMAS S & DONNA M
ADDRESS/PHONE 11 BEATTIE DR FLORENCE (413) 586 -6845 0
PROPERTY LOCATION 11 BEATTIE DR
MAP 29 PARCEL 206 001 ZONE URA(100) / /WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 4W Q 155
Fee Paid �(p�f J
Typeof Construction: ENCLOSE PORCH TO LIVING ROOM
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 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
a7-0-•
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.
I1 BuitriE bit 4 BP- 2010 -0387
GIS # COMMONWEALTH OF MASSACHUSETTS
u' :i3Toeic 29 - 206 7 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 -0387
Project # JS- 2010- 000509
Est. Cost: $2400.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 14461.92 Owner: WICHOWSKI THOMAS S & DONNA M
Zoning: URA(100) / /WSP Applicant: WICHOWSKI THOMAS S & DONNA M
AT: 11 BEATTIE DR
Applicant Address: Phone: Insurance:
11 BEATTIE DR (413) 586 -6845 O
FLORENCEMA01062 ISSUED ON:10/8/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: ENCLOSE PORCH TO LIVING ROOM
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 10/8/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
11 BEATTIE DR BP- 2010 -03$7
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 206 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categot _ BUILDING PERMIT
Permit # BP- 2010 -0387
Project t JS_20.10- 000509
Est. Cost: .',2400.00 •
Fee: $55,00 PERMISSION IS IIERE'BY GRANTED TO:
Const. C'i_� s: Contractor: License: •
Use Group_, _ Homeowner as Cc.itractor_
Lot sie1sscc , (1 .1_14461.92 Owner: WICHOWSI.I THOMAS S & DONNA M
Zonate i RA(100)i /WS' 4pplicatzt: WICHOWSKI THOMAS S & DONNA M
11.4: 1 E BEAT 1.iF l.)R
<- uplic(rnt Address: - - - - - -- Phone; Insurance:
11 BEA TIE DR _ (41) 585 -68
FLORENCEMA01062 ISSUED ON :10 / ?/ 2009 0 :00 :01
TO PERFORM THE FOLLOWING ;VOR ri; ENCLOSE PORCH TO LIVING ROOM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.i'. �'. Building inspector
Underground: Service: t;; , t:
Footings:
Rough: Rough: f ' House ;t Foundation:
Driveway Final: ✓` ,
Final: Final Jo - ! 6
Rough Frame: dip, al'
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation: O
Final: Smoke: Fin il: Q K 3 1 Z ' ( LIPAA 1 S
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMP'T'ON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. `t
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 10/8/2009 0:00:00 $55.00
•
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Corun;ssiotier - Anthony Patillo
•