23D-037 (2) City of Northampton
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DEPARTMENT OF BUILDING INSPECTIONS I C r
'71;w 212 Main Street • Municipal Building �Jj I' 4b!
`' Northampton, MA 01060 �sV ..K�1.‘� .
JV Y7.
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act a: his/her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parce on which
he/she resides or intends to be, a one or two family dwelling, attached or detached str tures
accessory to such use and/or farm structures. A person who constructs more than on: ome in a two-
year period shall not be considered a home owner."
The building department for the City of Northampton wants any person(s) •• seek to use the home
owner exemption, to act as their own construction supervisor, to be aw- - that by doing so you
become responsible for compliance with state building codes a, ■ regulations. The inspection
process requires that the building department be called to inspec i ork at various stages, which include
foundation/footings (before backfill), sonotube holes (bef• e pour), a rough building inspection
(before work is concealed), insulation inspection (if re• ired) and a final building inspection.
The building department requires these inspections bef• the work is concealed, failure to secure
these inspections can result in failure to obtain a -ertificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform irk (electrical, plumbing & gas) the homeowner will be
responsible to make sure that the trades hired ecure their proper permits in conjunction to the building
permit issued, and that they get their requ' ed 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 loc. on
/
The Commonwealth of Massachusetts
_ Department of Industrial Accidents
�` _ Office of Investigations
=�` '= 600 Washington Street
, 4 g
°�p� Boston, MA 02111
f�1 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): - `�' c�vh ' vA(-4)(;( S
Address: P (6g(0)c G " f F1C-t--9/ 0133 b
�T-- —Phone #: 4/2- – 6 Z. r -C,9,
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. El I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ® Demolition
working for me in any capacity. employees and have workers'
9. ❑Building addition
[No workers' comp.insurance comp. insurance.
required.] 5. We 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
12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
k�;
employees. [No workers' 13.E Other PA 2
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners 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.
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 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 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
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: lt1 EitZ>11 Date:
Phone#:
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: O `�C'� LA iJ C„S - o l} !
�` _ J� License Number
Pot,ay G I �\s � �) ®t 33 a Mkt k
Address Expiration Date
4t3 - 6tic- 6, y)
Signature Telephone
1‘10i k-AN
9.Re istered Home Improvement Contractor;' Not Applicable £
Company Name Registration Number
r,..0 • /�.(� - \ L --LEa\
AAddress G Expiration Date
1 ef G a ( &'I ( / /'o- Qr•33 O Telephone'l 3-CZf"6,lJ
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 oft building permit.
Signed Affidavit Attached es £ No £
11 -;Home Owner Exemption=
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings o . e(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a licens- .rovided 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 r-: .es or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached s res accessory to such use and/or farm
structures.A person who constructs more than one home in a two- • period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a fo•• acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the bu' : 2 permit.
As acting Construction Supervisor your presence • e job site will be required from time to time,during and upon
completion of the work for which this permit' 'ssued.
Also be advised that with reference to C.:,ter 152(Workers'Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resultin Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for :. under this permit.
The undersigned"horn-.• er"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton 0 • ances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
.l eowner Signature.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition E] Replacement Windows Alteration(s) Roofing El
Or Doors D
Accessory Bldg. ❑ Demolition New Signs [C]] Decks [CI Siding [0] Other[ ]
Brief Description of Propo ed ,�,()
Work: par Q� S\k*X�svc S P - /,,,eckES S/M''i
Alteration of existing bedroom Yes No Adding new bedroom Yes X/ No
Attached Narrative Renovating unfinished basement Yes ) No
Plans Attached Roll -Sheet
bar If.New'house:Yand:or:addifi n to existii ct housing;cornplefe.ttie fo(lowinct:
a. U.e of building:One Family Two Family Other
b. Numb- •f rooms in each family unit: Number of Bathrooms
c. Is there a gara•- attached?
d. Proposed Square foota•_ .f new construction. •' ensions
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 co . ction within 100 yr. floodplain Yes No
j. Depth of sement or cellar floor below finished grade
k. W' uilding conform to the Building and Zoning regulations? Yes No
t. 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
I, J c�n�.T'( � 1 C-e"-- c ^ ,as Owner of the subject
property
hereby authorize "A-((
to act on y behalf,in all matters relative to work authorized by this building permit application.
r✓f Y. I U 3 •
Signa r of Owner Date
Mirk L4 ,as,cwaer/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.
'l Wit L
Print Name
1f i
Sign. ure of,AwseF/Agent Dat.
r
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Info • •tion
Existing Proposed Required by .sning
This col, • o be filled in by
Buildi : Department
Lot Size I I t
Frontage .---_ _..._.____.___. _____ ___.__ .J [_._...__._._._____**..____._.•
Setbacks Front = 1 i Side L:= R= ∎ R:=
r
Rear 1.____f I 1 t--
Nir Building Height I- L. Tl i I
Bldg.Square Footage -1 F-1 % r'-` [__ 1] = -
Open Space Footage { { % }} i
(Lot area minus bldg&•. ed L..__w_� L___._.__1 L____,-:_( 1 _ J +----a
parking)
#of Par ' g Spaces
I I
ill: 1.._,...._.__..._......_...._....w.�.w.._,...._.. �_...�,..�..__...__. .._._.._�.,:......_._..�y
(volume&Location) 1 f
A. Has a Special Permit/Variance/Findi g ever been issued for/on the site?
NO Q DONT KNOW YES 0
.
IF YES, date issued:{
IF YES: Was the permit recorded at the Re istry of Deeds?
NO Q DONT KNOW YES 0
IF YES: enter Book 1 1--_—.._____~�� Page • and/or Document#1
i
B. Does the site contain a brook, body of water or wetlands? NO d 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 Q , Date I sued: (
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO
IF YES, describe size, type and location: J
E. Will the construction activity disturb(clearing,grading, exc vation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
..... J iT ,--T-T Cty of Northampton
4" Building Nov ;: 212 Main Street
Room 100
Iiorthampton k MA 0106 0
__. phone-41 -587-1240 Fax 413-587-1272
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APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed office . :
1.1 Property Address: byr t
h
it (16 ",1� U� Map Lot d Unit'
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F M o 166 1--- Zone : OverlayDistrcct
't ' d.: k 't i L I 3 d �' f r fs, y d i
eElm St District - CB District= ,+,c;r.
•. SECTION 2 r-PROPERTY OWNERSHIP/AUTHORIZED AGENT .
2.1 Owner of Record:
^-41164 6,e--f ay ) r o2 '"-°—6 PG/F'_.o/L c---c/ A„A- woc
Name Pn Current Mailing Address.
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Tel ep'rfe~ 5-Sr---5-9 G s
nature
2.2 Authorized Agent:
/1^4 ' ç -••fi rP 03?c 6 4c 'R c- o ,v14 o! D 30
Na e(Print) Current Mailing Address: /
st ►' ¢-(3 — C 2_1-- C ,_9j
Signa ure Telephone
•
.SEC ON 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant .
1. Building ( 0 6 (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
J
6. Total=(1 +2+3+4+5) 11- 0 0 0 Check Number /;.• . #-..‘(7
. : • • This:Section For Official Use Only
Building Permit Number: mste
. Issued: •
Signature: .• .
Building Commissioner/Inspector of Buildings • : . .Date
•
•
R,
File#BP-2014-0636
APPLICANT/CONTACT PERSON MARK LANDY
ADDRESS/PHONE P 0 BOX 61 ASHFIELD (413)625-6999 0
PROPERTY LOCATION 11 ORMOND DR
MAP 23D PARCEL 037 001 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 iek3 416-5
Fee Paid
Typeof Construction: ADD 2 SKYLIGHTS
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
INFO ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Peii[iit 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
Peiinit from Elm Street Commission _ Permit DPW Storm Water Management
•o "on elay
�/
_ _ 7/— /3
Signa re o 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.
11 ORMOND DR BP-2014-0636
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D-037 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-2014-0636
Project# JS-2014-001080
Est. Cost: $4000.00
Fee:$55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANDY 077431
Lot Size(sq. ft.): 7535.88 Owner: FOGELSON JONATHAN
Zoning:URB(100)/ Applicant: MARK LANDY
AT: 11 ORMOND DR
Applicant Address: Phone: Insurance:
P 0 BOX 61 (413) 625-6999 0
AS H F I E L D MA01330-0061 ISSUED ON:11/21/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD 2 SKYLIGHTS
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 11/21/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner