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"$ DEPARTMENT OF BUILDING INSPECTIONS — _i ;-
INSPECTOR ,
212 Main Street • Municipal Building 1
Northampton, MA 01060 .
',
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his /her construction sup<: •• sor. 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, 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
f • -
. , • ,
The Commonwealth of Massachusetts
i Department of Industrial Accidents
X41, ►= Office of Investigations
= 11. =miff 600 Washington Street
t. Sii : i Boston, MA 02111
w 5'' www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information 1 Please Print Legibly
Name (Business/Organization/Individual) yAi /t �,.44:47.c•Is f s4/Ti ett7 J 70 .
Address: /G` 4 �fe 1 ;1/ 2"`
City /State /Zip:/ar d %d Z Phone #: 4//3 1,6 7i
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
listed on the attached sheet. 7. ❑ Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance mp. insurance.
required.] 5. ee are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. [`Other /'4I4 6t/
comp. insurance required.]
*Any applicant that checks box #1 must 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.
1 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 25A of MGL c. 152 can lead to the imposition of crimingl 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 fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investieations of the DIA for insurance coverage verification.
I do hereby certify �,tderrtthe pains and penalties of perjury that the information provided correct.
�deed abovee is true and correc
Signature: ��' l �� /, Date: G Iy:7 J
Phone #: 4 j 7-1b ' /x
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 Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
' 8.1 Licensed Construction Supervisor: /� ���� Not Applicable ❑
Name of License Holder : ,.."-- < �/d/i�li+a �i€ e a I / f r
License Number
Address r/ Expiration ate
./ g/14•"---- 4Q 2 7)... — 4 . 3, e'
Signature Telephone
S.:Re` i nter 'ed,H'omeg(mprave iiiiit ntra k ` K , Y Y 1 Not Applicable ❑
.O ��Ii t"pf f /_ Tsrr 4 ,re..-7, rY4'j - _...4-09 - 1, A'/e/ 6 (// '
Company Name Registration Nunn r
Address " ,+� / r-�./ Expiration Date
/ //J Telephone '6 1 J"`'
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 ❑
1l Home wn�et x e Onon
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 be /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)
, a
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [I= Siding [O] Other,[j
Brief Description of Proposed ,/ - 77
Work: � .ege / �� / a.t i �i ? � G G f / lt /0 /4J& /.y /' '
Alteration of existing bedroom Yes /'Alo Adding new bedroom !/ No
Attached Narrative Renovating unfinished basement Yes L- No
Plans Attached Roll - Sheet
sa,If New house: Wd o additionto Ogiii q gadit t. rnptefe fie -foi a;V nq:
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 :CONTRACTORAPPLIES FOR PERMIT
I, pe. . v i r (S I-A fps , as Owner of the subject
prop
he eby authorize — Pa-ye AI Co i; ne
t■ act on my behalf in all matters relative to work authorized by this building permit application.
11'1, (rfl Z4, e/ .3 `b
Si.na ure of Own r Date
,c7' as Owner ut prized
c 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 Nam= �r 9
/ 4 /�
Signature . .'ner/ n Date
,,e / / / / if
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: L: R: �_` _ .
Rear `
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved j
parking) '
# of Parking Spaces
Fill: — .
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES 0
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 of water or wetlands? NO Q DON'T KNOW 0 YES Q
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:
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 Q
IF YES, then a Northampton Storm Water Management, Permit from the DPW is required.
r '
Department use only
City of Northampton Status of'ermth
Building Department Cu rte= -z ay anti
212 Main Street
Room 100 t et* a = �
1 L Northampton, MA 01060 o4-e o .St uctural ar •
h' phone 413- 587 -1240 Fax 413 -587 -1272 • �l s �` �� -
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
Y P 5? Map fi .tot " Umt
Zone ' . Overlay District
Efm St District =` CBA�stnct
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: /
rrC..L.. Or( S(zkcS 5GH +rnerd / rra Cc'_
Nam (Print) , Curre i M ailing 7?3& Address:
�7 4(-- I/ dJ/4- G Teleph e'
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 (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 d
6. Total = (1 + 2 + 3 + 4 + 5) 4/ ffQa Check Number /pq:2
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0909
APPLICANT /CONTACT PERSON DAVID CHICOINE
ADDRESS /PHONE 16 EDGE HILL PLACE AMHERST (413) 246 -7536
PROPERTY LOCATION 36 POMEROY TER
MAP 32A PARCEL 233 001 ZONE SC(42)/URC(58)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 49� 5J
Fee Paid
Typeof Construction: INSTALL CELLULOSE INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 061582
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN, F^MATION PRESENTED:
V 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
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.
•
36 POMEROY TER BP -2010 -0909
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 233 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-2010-0909
Project # JS- 2010- 001345
Est. Cost: $800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID CHICOINE 061582
Lot Size(sq. ft.): 23348.16 Owner: CHRISTAKOS PETER G & DEBORAH S
Zoning: SC(42)/URC(58)/ Applicant: DAVID CH I COIN E
AT: 36 POMEROY TER
Applicant Address: ;hone: Insurance:
16 EDGE HILL PLACE (413) 246 -7536
AMHERSTMA01002 ISSUED ON:4/20/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL CELLULOSE INSULATION
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:
Fi ._.. Smoke: Final: 06 �1i F ( 16 /01.41,5
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy , > 1 4 1 1 (1 --� �t. signature: �' t2�
FeeType: Date Paid: Amount:
Building 4/20/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo