17D-080 (2) Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS -011620
JOHN E KELLY
PO BOX 1271 "`
East Otis MA 01929 c ' ��
"' Expiration
Commissioner 04/18/2014
SECTION 5- DESCRIPTION OF PROPOSED WORK fcheck alf
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [EJ Siding [0] Other [0]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa If lew,liou • ;- oriaddition to existing* oustrtg`3 sirrtplefe' halo towrhq:
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 BECOMPLETED
.OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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 D ate
, 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
............
CH filoc I N CSL — HABITAT � l o �sf -
3 gAr_f(E D 1 , 7 v ,. g
SECTION 8 ;CONSTRUCTION SERVICES --
8.1 Licensed Construction Supervisor: Applicable ❑
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Name of License Holder : \j 0 . L f e_ ('� 7/
vd / License Number
Address Expiration Date
Signature T elephone /
‘: /// 1 7 1
41„./E. 4
is eke"; om-- m'rove . 411. "tra o ; .). r. . F< .i _ , #n Not Applicable ❑
T
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Company Name ' •.� / Registration Number
Address Expiration Date
Telep e
SE 1 0- ',_WORKERS' COMPENSATION INSURANCE AFFID (M G.L c 152, § ,
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 ❑
° o 1 . wi er. en ptio
E
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 1083.5.1.
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
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