17B-015 (5) -- City of Northampton
/ _•}'' r Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
r M ' 212 Main Street • Municipal Building
Northampton, MA 01060
W ei�
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
1`\ /,17
The Sta of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act his/her
constructio supervisor. The state defines "Homeowner" as, " Person(s) who owns a par I on which
he/she reside r intends to be, a one or two family dwelling, attached or detached uctures
accessory to suc use and/or farm structures. A person who constructs more than a home in a two-
year period shall no a considered a home owner."
The building department f the City of Northampton wants any person(s) o seek to use the home
owner exemption, to act as th ' own construction supervisor, to be aw that by doing so you
become responsible for comp nce with state building codes a regulations. The inspection
process requires that the building d artment be called to inspect ork at various stages, which include
foundation/footings before backfill onotube holes befo our a rou h buildin ins ection
before work is concealed insulation s ection if re red and a final buildin ins ection.
The building department requires these insp tions befor he work is concealed, failure to secure
these ins ections can result in failure to ob 'n a c ificate of occu anc until the work can be
inspected.
If the homeowner hires other trades to perform w ectrical, plumbing & gas)the homeowner will be
responsible to make sure that the trades hired ecure th ' proper permits in conjunction to the building
permit issued, and that they get their req ' ed inspectio . Failure of the individual trades to secure
the permits and inspections as required n DELAY the proje until such time as the proper permits
and inspections are made
I, unde and the above.
(Home owner/resident's gnature requesting exemption)
I will call to schedule all re red building inspections necessary for the buil permit issued to me.
Date
Address of work cation
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: e
City/State/Zip: Phone #:
Are you an employer? Check the a opriate 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. El New construction
2.I�/ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance. 1 F-1 Building addition
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.❑ 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' 13.21 Other
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.
Sip-nature- -IgL Date:
Phone#: Y/3- ss-49
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: 94/5?
License Number
a. 7-/3
Address Expiration Date
3-X95"-7GS9
Signature Telephone
9:'Reg fit ered Home.lmprovemenfCdntractor Not Applicable £
Company Na Registration Number
. &W 6 2 S - 3
Address Expiration Date
Telephone 7/3`�q-5�7
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...... £
1 Rome Owner.Egem tion
The current exem for"homeowners"was extended to include Owner-occupied Dwellings of one(1) o(2)families
and to allow such homed er to engage an individual for hire who does not possess a license, rovid at the owner acts
as supervisor.CMR 780 Six Edition Section 108.3.5.1.
Definition of Homeowner:Person ho own a parcel of land on which he/she resi �inteds o reside,on which there
is,or is intended to be,a one or two family elling,attached or detached struc s accessory to such use and/or farm
structures.A person who constructs more than home in a two- ea rind shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Officia, a fo ceptable to the Building Official,that he/she shall be
responsible for all such work performed under the b ' 2 t.
As acting Construction Supervisor your prese n the job site will uired from time to time,during and upon
completion of the work for which this pe ' is issued.
Also be advised that with refere o Chapter 152(Workers'Compensation) and Ch r 153(Liability of Employers to
Employees for injuries resulting in Death)of the Massachusetts General Laws Annotate , u ma be liable for person(s)
you hire to perf work for you under this permit.
The unde ed"homeowner"certifies and assumes responsibility for compliance with the State Buil Code,City of
No mpton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotate .
Homeowner Signature.
k
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [2f Siding[O] Other[a�
Brief Description of Proposed
Work: l _ / isra.e Sc
Alteration of existing bedroom Yes V No Adding new bedroom Yes V'1 No /
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. If< ew-hotise`and.oraddifon to`�'existin �h"OUSIn cam lete thefallowin ":
a. Use of bw : One Family Two Family Other
b. Number of rooms i ch family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new con ction. Dime ns
e. Number of stories?
f. Method of heating? eplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Massche nergy Compliance form attached?
h. Type of construction
i. Is construction withi ft.of wetlands? Yes No. Is construction within 1 r. floodplain Yes No
j. Depth of ement or cellar floor below finished grade
k. 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
I,X as Owner of the subject
pro rty
hereby authorize E44za
to act n my behalf, in all matters relative ork authorized by this building permit application.
�Q
S natu a of Owner Dat
as Owner/Authorized
Agent hereby declare tha 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.
Print Name
7 2061
Signature of 0 r/Agent D e
�
� m
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
11iis column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
Fill: j
(volume&Location)
A. Has Special Permit/Variance/Rnding ever been issued for/on the site?
x~� �~�
NO «�~��� DONTKNO�/ x�� YES �~�
IF YES, date' .�_-____-_____]
IF YES: Was the permit recorded at the Registry ofDeeds?
NO K j D
~� -'
IF YES: enter Book Pageand/or Document#L
B. Does the site contain a brook, body uf water nrwetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained �-� Obtained x~~� Date^=� �~� ' .
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size 'typeand location:
D. Are there any proposed changes toor additions of signs intended for the property 7 YES ��'»�� «_�
NO �-*
IF YES, describe size, type an d location:
E. Will the construction activity disturb(clearing, grading,excavation,or filling)over 1 acre orioit part nfa common plan
, that will disturb over 1acre? YESK��] NO ����
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
s This section to be completetl by office
1.1 Property Address:
RR
, ! 4
F Zone Overlay District
r a'
� • t i �1 41 f�11 -i 1 P ..1:
Elm St rRistnct CB Dlstnct c+
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
��,�/� e�� X399
Name(Print) Curren i ailing ress:
�► - 55 - 61G �j
XCCZ86ta. _ Telephone
Signatur
2.2 Authorized Agent:
2 Ola9G
Name(Print) Current Mailing Address:
V/3
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS. .
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building pa (a)Building Permit Fee
1 g80.
2. Electrical (b)Estimated Total Cost of
Construction`from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Q vo Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector'of Buildings Date
File#BP-2014-0876
APPLICANT/CONTACT PERSON EDWARD RICKEY
ADDRESS/PHONE P O BOX 62 WILLIAMSBURG (413)695-7059
PROPERTY LOCATION 399 BRIDGE RD
MAP 17B PARCEL 015 000 ZONE URB(189)/WP(79)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: REPLACE STAIRS(UNIT D) INSTALL RAILINGS A,B,C,D
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 96159
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 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
ABm ion Delay
fficial Da te
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.
399 BRIDGE RD BP-2014-0876
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 17B-015 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2014-0876
Project# JS-2014-001529
Est.Cost: $1880.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: EDWARD RICKEY 96159
Lot Size(sq. ft.): Owner: OSTRANDER DENNIS W&JEANNE F BECK-OSTRANDER
Zoning.URB(189)//WP(79) Applicant. EDWARD RICKEY
AT. 399 BRIDGE RD
Applicant Address: Phone: Insurance:
P O BOX 62 (413) 695-7059 WC
WILLIAMSBURGMA01096 ISSUED ON:211912014 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE STAIRS (UNIT D), INSTALL RAILINGS
@ A,B,C,D
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 2/19/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner