36-075 (3) City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
xjicensed solid waste disposal facility, as defined by MGL c 111, S 150A.
f L/Address of the work: li`�
The debris will be transported b
f' The debris will be received by:
Building permit number:
Name of Permit Applicant U
i ;
Date Signatu e of Permit plicant
City of Northampton
�A Massachusetts Z{
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DEPARTMENT OF BUILDING INSPECTXOATS i
212 Main Street • Municipal Building vl'•:. b:
'�= �,,.•. Northampton, MA 01060
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 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 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 b ilding department requires these inspections before the work is concealed,failure to secure
these 'ns ections can result in failure to obtain a certificate of occupancy until the work can be
ins ec ed.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be
responsihle,klto 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
th errrtits pd inspections as required can DELAY the project until such time as the proper permits
a spe tiors e made
l
understand the above.
(H We o e dent's signature requesting exemption)
will call to sc le II required building inspections necessary for the building permit issued to me.
Date ) 1>
Address of work location
I
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
i - Office of Investigations
600 Washington Street
i Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractor.s/Llectricians/Plumbers
Applicant Information Please Print LeLribly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate bog: Type of project(required):
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
2.❑ 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' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
5. ❑ We are:a corporation and its 10.❑ Electrical repairs or additions
required.]
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.❑ 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-itd4#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy ofkers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure e as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $ 500r one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$25 .00 'Anst the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigatio s of for insurance coverage verification.
r
I do herey ertify e pain penalties ofperjury that the information provided above is true and correct.
2'0 1
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
License Number
Address Expiration Date
Signature Telephone
9.Re4istered Home lmbrovernent Contractor ;; Not Applicable £
Company Name Registration Number
Address Expiration Date
Telephone
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...... £
11 Home Qwner Egempt><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 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 elling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs mori tan one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the 41d' g Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performdd ulader the buildin2 permit.
As acting Construction Supervisor yo p esence on the job site will be required from time to time,during and upon
completion of the work for which this p t is issued.
Also be advised that with refere c,to a ter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resu ing in th)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for y under t 's ermit.
The undersigned"homeo er' certifie an assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,St a d L al o g Laws and State of Massachusetts General Laws Annotated.
Iomeowner Signature
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [] Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors C7
Accessory Bidg. ❑ Demolition ❑ New Signs [p] Decks [0 Siding[0] Other[C7]
Brie Description of Pro sed
ork:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa if�lew.house and or:addltlorrto exi5fingFrousiiriq,.corfipafete fhe.foFlowing
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
SECTION 7a-OWNER AUTHORIZATION-TO.BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR.BUILDING PERMIT'
I, as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, R as Owner/Authorized
Age hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and b ief.
S ned u` er the pains and penalties of perjury.
Pri t Na
nature o wner/Agent a
" ^
Section 4. ZONING AR Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Tb�is coluam to�e filled in by
Building Deparftrignt,
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage "a
Open Space Footage
(Lot area minus bldg&payed
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Variance/Find' ver been issued for/on the site?
NO �_v�\/ DONT KNOW YES �~x—�
�
|F YES, date,issued* �
IF YES: Was the permit recorded at the Registry ofDeeds? .
NO x��
DONTKNOW /ES '
���
IF YES: enter Bonk P and/or Document#
�� ��
B. Does the� ��site a brook, body NO �^� OONT KNOW �,� YES ��, �
IF YES, has permit been or need to beobtained from the Conservation Commission?
Needs to be obtained �-� Obtained y~� Date �
��/ �~/ ' .
C. Oo any signs exist on the property? �~\� YE� �^� NO �^v���
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, gradingexcavation, or filling)over 1 acre orioit part ofa common plan
that will disturb over 1acre? YES NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required. �
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uil ing Department jymay Permi# r
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NoaTM' ne 413-587-1240 Fax 413-587-1272 PIo:f/SICe Plansr$ * r
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APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION
SThissectiorr;fc be coin letedb:':-
1 Pro a Address:
�aS�fIL�M�/rrs� =°I111ap- Lot Umt
yin« e, z h
Qverlay Disfrtct ! ...__. •;
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SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED.AGENT:
2.1 Owner f Record:
Na a Current Mailing Address: '//> :2-36 5 L,, -
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS. .
Item Estimated Cost(Dollars)to be Official Use-Only
completed by ermit applicant
Building (a) Building'Permit Fee
coy
2. Electrical . (b) Estimated Total'Cost of
tons truction'froM 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection dq
6. Total=(1 +2+3+4+5) Check Number
This-Section For Official Use*Only
Date
Building Permit Number: Issued:
Signature:
Build(ng Commissioner/lnspector'of Buildings Date
363 WESTHAMPTON RD BP-2016-0648
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-075 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Quildbg DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2016-0648
Project# JS-2016-001091
Est. Cost: $4000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 93697.56 Owner: HOENER VIRGINIA H
Zoning: Applicant. HOENER VIRGINIA H
AT. 363 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
45 PINE ST (413) 230-9415-0
FLORENCEMA01062 ISSUED ON:111912015 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
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 11/9/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner