17A-058 (5) 1 crity II I7 �llt T iI7T s
� � �iiassacf{usetfs �.
<s� DEPP_RTMENT OF BUILDf.�G INSPECTIONS
INSPECTOR 212 Main Street 0 Municipal BtuldinD.-
O,V
North'unpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMM 108.3.4 to
act as i3is/l:er construction sup : . i_or. 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 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 regula tions. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before back-fill).
sonotube holes (before pour). a rough building inspection(before work is
concealed), insulation inspection if required) and a_fnal_build.ina 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 occupancv
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. V
Date
Address of work
location
The Commonwealth of Massachusetts
Department of In dustrial Accidents
Office of Investigations
Q' 600 Washington Street
Boston,ALA 02111
5. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Na$e (Business/Organization/Individual): �� } � �5 D� �y b e f2 S
Address: �� y
City/State/Zip:)hjb, t 4Th c), &t1-. Ot o(<- Phone 9: 14"-71-8.1
Are you an employer?Check the appropriate box:
Type of project(rewired):
1.❑ I am a employer with 4. [] I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no=,loyees These sub-contractors have S. Demolition
working or me in an capacity. employees and have workers'
� Y P tY• 9. ❑Building addition
[No workers' comp.insurance comp. insurance.+
required.] 5. F� We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 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.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 131-1 Other
comp. insurance required.]
- v - --..
Y aPP—ham a c ec oox must a o it out- a section ow s owing etr wor comQensatioa policy infora�tion.
Homeowners 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.
lam 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 S 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 S250.00 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 ce under the pain d penalties of perjury that the information provided above is true and correct
-- - --
(, �2S
_—�ignafure. Date:
Phone#: -7q e, 5
vfficiai use only. Do not write in this area,to be completed by city or town g07ciaL �
City or Town: Permit/License
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone 7:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
0'0 6/ LINO P
Add- fir. Expiration Date
Sign ture Telephone
9.'RediStered Florne TriipEiveiiret Coittrao€o . _� _ '1 Not Applicable ❑
-sExr
-J-D)2- Zyl►�-C'� Cl2S 1363`) 7
Company Name Registration Number
x � �- �, .�, �51-3 3h,
,� ►
Address Expiration Date
Telephone 3 - 7 0
SECTION 10-WORKERS?COMPENSATION,INSURANCEAFFiDA1l1T(M:G.L c-1i52,,§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...... ❑
ERI X01
, i
+ > 1RM-i-lam
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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors F-1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[O] Other[0]
Brief Desrr. ti n of Proposed
Work: ►P PZE2x,*-1F V))R f . S f{r,�sUIES. l E✓��G tv rJ rr� LAr�1 �LL
Altermion of ez(sting Ucd=m Yes No Adding newtedroom Yes y No
Attached Narrative Renovating unfinished basement Yes ?'_No
Plans Attached Roll -Sheet
6a It IVevrc tivuse°arzd aF acfd� r'an_#a: xFS#��t`i€ rouscct�.coin E# e a Cain�ir g:
a. Use of building:One Family Two Family Other
b. Number of rooms in ea6h 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. ~ ___M4sscheck Energy Compliance form attached?
e�
h. Type of construction M`tom
s-i. Is construction within 100 ft.of wetlands? Yes o.
Depth of basement or cellar flo below finished grade
k. Will building conform to Building and Zoning regulations? Yes No.
I, Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER,AUTHORIZATION TO BE COMIPLETED:WHEN
OWNERS.AGENT-OR GONTIZAGTOR APPLIES:FOR,•bt)ILDINC::PERN1l;T
I, C-�uC LCD- �f Ci fi4CNrlc IJ as Owner of the subject
property
herebyauthodze AMPS �. A SS
to act on my bB,eitaflff,, in all matters relative to work authorized by this building permit application.
Jan
Signature of 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.
Sig under the pai d penalties of perjury.
Print me !\✓
Signature of Owner/Agent Date
° -
~
KSection 4. ZONING I All Information Mu5t Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Z
This column to be filled in by
Buildin.-Department
Lot Size
Setbacks Front
Side R-
Rear
Building Height
ge
Open Space Footage
(Lot area minus bidg&paved
#of Parking Spaces
`
(volume&Location)
A Has a Special Permit/Variance/Finding ever been issued for/on the site?
OGNnF--.. _ ~~� ���----__--------
IF YES, date bsued '
IF YES: Was the permit recorded ut the Registry u[Deeds?
NO �� D
�~/ u/v / xmuvv 0 YES
�
IF YES: enter Book Page/ and/or Ducument�( �
B. Dues the site contain a brook, body of water or wetlands? NO DON7KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained �-1 Obtained �~\ Da�e�omm6'
^~� �~� ' .
C. Do any signs exist on the property? YE5 �-\ NO �7`
- �
IF YE3, describe size' type and location:
O. Are there any ' - intandedforUhepmperty? YES - NO x�X
IF YES, describe size, type and location:
E. Will the constmodon activity disturb .grading,excavation,or filling)over 1 acre nrish part cfo common plan
that will disturb over 1acre? YES � l NO n�� k�ok
IF YES,then a Northampton Storm Water Management Permit from the DPW is required
City of Northampton taaf Peen a
Building Department iewef?errnr
212 Main Street 'bawei�'s 5trdW aita T �
Room 100 rafes�etE4 �#al�r � r z
Northampton, MA 01060 _
�,-
phone 413-587-1240 Fax 413-587-1272 l?tafSe FFan
dtttBG"$peed
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTIOU-A-SITE INFORMATION,
n rs tectioM't0 be campleteci b offj.
1.1 Property Address:
° Tti
19 i>G+E Lax Ucrrl
FIL" -Zone O�erlayDrstsrct ..
t»D�scf .-"i7N_ " - -C1Distrrct_ -
SECT-10t4 2-PROPERTY OWNERSHIPPAUTHORIZ App _—_
F2_�10:wner of Record:f(�Gttt
Name(Print) Current Mailing Addres :
Telephone
2.2 Authorized Agent:
Name(P "nt) Current Mailing Address:
\J 3 -74-
Signature Telephone
SECTION 3-ESTIVATEQ: CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be official Use Only
completed by ermit applicant
1. Building , -(ayBuilding?Permit Fee
2. Electrical (by'Estimated Totat,Cost_of
Construction.from 6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6, Total=(1 +2+3+4+5) 1,-7a. Check Number �-
Tttis Section-For Offciaktlse Only
Building-Permit Number.. 'lssued:
Signature:
Building Commissioner/Inspector of Buildings Date
197 BRIDGE RD BP-2008-0350
GIs#: COMMONWEALTH OF MASSACHUSETTS
M Block: 17A-058 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: BUILDING PERMIT
Permit# BP-2008-0350
Project# JS-2008-000500
Est. Cost: $1700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Cor)s". Class: Contractor: License:
Use Groin: JDR BUILDERS 130397
Lot Size(sd ft.): 11761.20 Owner: DEGRANDPRE PA1 RICIA
Zoning: URB Applicant: JDR BUILDERS
AT- 107 RP!n F 9D
Applicant Address: -- _Phone: Insurance:
P O BOX 66 (41 3) 665-7587
WHATELYMA01093-0066 ISSUED ON.101112007 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
tJnderground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
S're'ke: _ Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature: r
FeeType: Date Paid: Amount:
Building 10/1/2007 0:00:00 $25.002826 AP& 3 0 2008
A. '�j ;LJ
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo y