17A-207 (8) MARK LADD & SON
CONSTRUCTION
MA UC. 0040771
CU- Z7-- C)
P.O. BOX 308
CONWAY, MA 01341
(413) 369-4294
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DEPARTMENT OF BUILDIJ\7G INSPECTIONS /=
INSPECTOR '212 Main Street • Municipal Building
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,::-,,i sor. T he 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
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DEPARTMENT OP BUILDf)\'G INSPECT101.'S -
212 Main Strcct ' Municipal Building
?Northampton, Mass. 01060
WORKER'S COi•III'I;NSATION LIS URA CE AFIII),' .Vj-j"
(l1 ccasxJpermi ticc)
%„-ith a principal place of business residence at: ----
7z3 Stt” 14JL (pitons;') - Zrj
e-ON"U: A-If 6A4 0��`�( (sir ticity/sZatcdzip) ��
do hereby cefdfj� under dic.paiu s 2nd penzlties of pcgury -hat
tl<,-am an employer providing the following %vorker's eolnoensado, cove age for 111y
emplovecs working on tilis job:
(Incur-_nom Con=-Ml) (Polic:?:u_-nrr_r) 001 (_:pir�tior.Dztc}
O I am a sole proprietor, general contractor or homeow-Der (c cie one) and have hired
[.he contractors iiste-� below wbo hzve the folio%vino worker's policies:
0-;3rac Oi CO"rmaor) (In ur3nc:Colnoan)•ipouc; NILI- t,--) Datc)
(Namc of Cootraor) (fns uane Comoaawpobc-' NuMcct) (-E.%p r,:tion Date)
(Name of Connaca&) (Insvranc; Company[POL-cJ Nwnb1 --r) (Expi boa Datc)
(Name of Contractor) (Lnsuranc-- Comraay/Policy Numbcr) (Expi-,600 Date).
(aII �di oC31 L'10C,tf ncocu�-ta mGV�iaroraA;oc pctn,a:n6 to.1J Cca.T-GA.�) .
O I am a sole proprietor and bave no one workiog for me-
( ) I am.a home owner perfor=g all the work myself.
NOTE:plesc be awart tfi••M WG t�CmC01��CT7 lib0 C$IjIQy Pc' II IA da -• c.-4=oo c road work oa.d-•e -Z of
aoc mcce th_a t-z -unk,in%&+nch the bomo wD(=mach or oc the p-wacI,z,7�tbeee,we Cx.12y oc-c:d.-ni to Lc
ei:plcy—uade the.. oc=pc- -,as Act(GL!152-a 1(5)�:.ppUc Eca by a homco.-=fc a lic:z:cc permit zy e�id—tL•e
lcgsl rL= of as-=Ploy. under d-WorkoeL C.oa pamatioa AeL
[uadc-a.aad the a copy o!chid¢stcmcn n y b<foc-xardod to tbo D of LNixL=i-1 Acoac -e Qffi-o(Itsunno.for Lb-
clove-age Ycira2ioa dad a"- Lijtzt to sears tov"-Aa ucdC 4c:joa 23A of MOL 152 can tcd to the impositioa •16-
corm ma of a Gx of up to 51-�00.00 afld/pr of up to ooc y=tDd cki1 pcaxhia in ttc form of a Stop Work Ord-dad
C=of S 100.00 a d.-y tptic:a me
/ For d,,-,xul u. only
PclMrt NUML—z
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Si�nacun of L ctm dcc e �`
SECTION 8-CONSTRUCTION SERVICES 71
8.1 Licensed Construction Supervisor.so � ,Q Not Applicable ❑
Name of License Holder: MW "-"-J� 040 *7-71
License Number
_ 223 5 cK_26yP-rte IAA Con�w h�t OA& (2 zi - 04
Address Expiration Date
9(3 - - 1474 q
Signature Telephone
Not Applicable ❑
9">Zeaister`ecl`tfiorrie lmriraye"rrieri�Coiitrac�#or
�aS fSt`5'�5
Company Name Registration Num er --_-—
Address Expiration Date
Z3 S $w,e-►t/ (� Telephone Y14'L(Z`IY
Coniu;l 0 7OLf
SECTION 10-WORKERS'"COMPENSATION INSURANCE AFFIDAYfT(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...... ❑
F
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 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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SECTION 5-DESCRIPTION OF PROPOSED WORK(check:atl applicable)
New House ❑ Addition ❑ . Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors Cl
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [ Siding[O] Other[[31
Brief De=r'iption of Proposed L,
Work: k� ALQ (�G� 0�P OF ft/St � LOK&Ifez TC PlAytc.
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet ✓
i d a rao ee e oFsa If-'#*,, owim.
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.
1. Septic Tank City Sewer Private well City water Supply
CTION 7a OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR.`APPLIES FOR BUILDING,-,PERMIT-
I, 0`ftj"Y as Owner of the subject
property
hereby authorize '`f�—
to act my behalf,in all matters relative to work authorized by this building permit application.
c__a C A� -2-.q -CI)Zf
Signatur o Owner Date
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.
LAWS
Print Name
IM
Signature of Owner/A nt Date
Section 4. ZONING All Informatioh 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 (zo
Setbacks Front 1 0 ,
Zc -=
Side L: R: �iS L. R: f ;
Rear
ZA
Building Height ; - -- --
Bldg. Square Footage % I �1SL�
Open Space Footage % ;
(Lot area minus bldg&paved
Parking) �•J�
3 F
#of Parking Spaces
Fill: AIOO jc T NNA
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW Q YES Q
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T 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 DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
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:
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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
-e Northampton
B Ing Department r
-—t �i2'.Main Street Seiivver sew iI ;
_-
'Room 100 f aOr
- 4oq pton MA 01060 ets Str afar s�
phone 413-�87-1i240 Fax 413-587-1272 t tot�s�t�ia�ts
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I,-SITE INFORMATION
o ffn to be compd y oce
1 1 Propert y Address:
�� =
131 rJ. 0"Lle, sT �-
�1� Zone verlay D�stnct
Elm St:Distr►ct i
a
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZID AGE
a
.1 Owner of Record:
� r 31 IV- 0,11K E S
Name(Print) Current Mailing Add ss: (`
Telephone 7
Signat /
2.2 A thorized Agent:
Name(Print) Current Mailing Address: 013"11
q l 3— 36�� `f Z?y vi
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item ~ Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee L04 Cov.
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building,Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) JC GCS,— Check Number I
This Section`For Official Use Only
,Date':
Building Permit Number Issued:
Signature:
i
Building Commissioner/Inspector of Buildings Date
File#BP-2005-0441
APPLICANT/CONTACT PERSON MARK LADD
ADDRESS/PHONE 223 SHELBURNE FALLS RD CONWAY (413)369-4294
PROPERTY LOCATION 131 NORTH MAPLE ST
MAP 17A PARCEL 207 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT REAR DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 040771
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOPIATION PRESENTED:
pproved 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
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.
131 NORTH MAPLE ST BP-2005-0441
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-207 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-2005-0441
Project# JS-2005-0585
Est.Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group: MARK LADD 040771
Lot Size(sg.ft.): 49222.80 Owner: WALDER MARTIN J&JOAN
Zoning URB Applicant: MARK LADD
AT: 131 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
223 SHELBURNE FALLS RD (413) 369-4294
CONWAYMA01341-9701 ISSUED ON.1114104 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 370 SQ FT REAR DECK
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: Receipt No: Date Paid: Check No: Amount:
Building 11/4/04 0:00:00 2852 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo