23D-004 (2) •
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
• • .O f NI- •t •- ••, •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
pits-in-conjunction-to-the_huilding-permitissued,_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 'me as the proper permits and inspections are
made
`�yq4Q`r
understand the above.
(Home owner/reside s signature requesting exemption)
I will call to schedule required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
The Commonwealth of Massachusetts
�, Department of Industrial Accidents
--.E.-_--„tirW.P Office of Investigations
_ �_
600 Washington Street
cr j Boston,MA 02111
www.massgov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Apnlicant Information t Please Print Legibly
Name (Business/Organization/Individual): it 4,RN
Address: 1. 341( U
City/State/Zip: ki\, ,t4LA t Mi r&>1130 . Phone#: 40- iN
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with 4. 0 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New constriction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. f Remodeling
ship and have no employees These sub-contractors have. 8. X]Demolition
working for me in any capacity. employees and have workers'
9. u-Buddiag addition
,ns ce..
[No workers'comp.insurance cow i
required] 5. X We are a corporation and its 10.0 Electrical repairs or additions
3.0 3 am-a hemeowne ioing-all--work- -- -- _---o -lave'xezcised their _ ❑Plumbing r epairs 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.i2 Other Cs rt1'�Sl
comp.insurance required] 66`
*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.
TContractors 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 wader Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 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. Ike 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 istrueiznd.correct-__
P.•tire 'N IWAI V&A i NNM■MMMMMMMNMMMIMIMMIIIMIMIMIIIIIP.
Phone#: �'`
3:2-'51 i 1 i -
Official use on Do not write in this area,to be completed by city or town official
Ci y or Town: Permit/License#
Issuing Authority(circle one):
1.-Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
6.Other
Contact Person: Phone#: -
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: \AfttilL Vikwdt C5 ..4141-41
License Number
b1 MA a 01330 -4)114
Address Expira Date
443 — 62c—LgetzC
Signattre Telephone
9.,Rectisten:i_,Home lm br'ovementGio~tractor ,, a Not Applicable ❑
ikA ct \-Aft DAsk 7)ymL S1 a;3i 111bT7
Company Name Registr tion Number
1)tbi 1,‘ ti)(141
Address p Expiration Date
� � \t"1�a lr 1.3343 Telephone 11-S"lDg ` 1
—
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 ❑
/.mtliorernerm: 11 on
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 ofland 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/ 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
o amptoh•r•ltlances, i . e • i • • • 1 •- ,. .' •-"v. --a v #.• °s- raiLaws-Annotated.•
Homeowner Signature
//7"4-‘-
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
�{ Or Doors El
Accessory Bldg. El Demolition L�1 New Signs [0] Decks [D Siding[el Other[D]
'‘tG 1r f2 4u+1 At4401 N loktivri
Iofck {tto Brief Description of Propose
Work: C-An+. tsc S Q tAlAi 1►141X a fl 1t4 011► 6't�''lieaa /ZtY!" Nt° a La�►�va-�
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
if New-hotiae:,ant or.additi t to°existing'housiiiq;>:lcoinp(ete_tie foifowinq:
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? 1!"'
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 CONTRACTOR APPLIES FOR BUILDING PERMIT
4: e s as Owner of the subject
property
hereby authorize 1,4 1 to act on my behalf, in all matters relatwork authorized by this building permit application.
Signature of Owner Date
\,A A( ..43e4 , as C ¢ler/Authorized
Agent hereby declare that a 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.
MileA 1.004=11
%A. kANAA
c to 14
Signatur ofdw ec/Agent Dat-
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 iab�
Building Department` }.' i ro
waw.
Lot Size '`
Frontage
Setbacks Front " ,
Side L._....,_.,. R. ___....w /L.:_.. ....:. R.. .._____
t'
Rear ..µ.. ,
Building Height
Bldg.Square Footage 7--- I ' o%a r -
1.
Open Space Footage _——i
(Lot area minus bldg&paved
parking)
#of Parking Spaces _ --- _,... ._ _
Fill: r—._ . —11 _ __
(volume&Location) ---.--._ ,_.._.�... ._.__,._.. ..,__
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW ei YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW (3 YES 0
IF YES: enter Book j Page: and/or Document#
r.B. Does the site contain a brook, body of water or wetlands? NO 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 , Date Issued:
C. Do any signs exist on the property? YES 0 NO (3
IF YES, describe size, type and location
'D:-Are there any proposedcianges o ora ittons o _stgt intendedfoit1i property? YES 0 NO
IF YES, describe size, type and location:
^
E. Will the construction activity disturb(clearing,grading,ex ion,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm WaterManagement Permit from the DPW is required.
RECEIVED t��7 ® ®a� itortly� �b a
•'ty of Northampton tasolF`� rt � � ;
B ilding Department
3 ZQ13 212 Main Street
Room 100
o hampton, MA 01060 e ��� � �
ten OF BUILDlNG 'PECTIO *'�
N13- 87-1240 Fax 413-587-1272
NORTHAMPTON f3+
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
t <�_r_ Map Lot Unit
fl C3
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:14-,
Name(Print) Current Mailing Address:
Se } Telephone J
Signat re 5/ f — s-
2.2 Authorized Agent:
MArk LANA.y IA<.`tcx bi PtsWWW.ntbt VO, LSj,330
Name(Print) Current Mailing Address:
4i3 - b L - 6111
Signatu Telephone
SECT! N 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 3 c.O Q (a)Building Permit Fee
2. Electrical ..tea (b)Estimated Total Cost of
Construction from16)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) vo Cfaeck Number Gov 1
This Section For lifietal Use Only
Building Permit Number: Date
- _ Issued:
Signature:
Building Commissionertlnspector:of Buildings-" Date
File#BP-2013-1088
APPLICANT/CONTACT PERSON MARK LANDY
ADDRESS/PHONE P 0 BOX 61 ASHFIELD (413)625-6999 0
PROPERTY LOCATION 15 NONOTUCK ST
MAP 23D PARCEL 004 001 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 i06219- I/37c
Typeof Construction: REPAIR ROTTED WOOD,PORCH,WINDOW,BULKHEAD
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 077431
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQ NIATION 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
Air
1,7p . 0.
r
64/- SI /3
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.
15 NONOTUCK ST BP-2013-1088
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D-004 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-2013-1088
Project# JS-2013-001793
Est. Cost: $3500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANDY 077431
Lot Size(sq. ft.): 5270.76 Owner: SHALLCROSS DORIS J TRUSTEE
Zoning:URB(100)/ Applicant: MARK LANDY
AT: 15 NONOTUCK ST
Applicant Address: Phone: Insurance:
P O BOX 61 (413) 625-6999 ()
AS H F I E L D MA01330-0061 ISSUED ON:5/14/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR ROTTED WOOD, PORCH, WINDOW,
BULKHEAD
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 5/14/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner