18-033 (2) • City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS =
212 Main Street • Municipal Building
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 backfili), 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
1, 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
5 600 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): 1 P/2 S'TD%J t"ARrn E7.S L"
Address: I/LS Ri V eg Si -
City /State /Zip: 1 3 7 7 4 0 l 1 t ) O T o l d [ i 7 Phone #: 51 ~ V ? - ' 73/j
Are you an employer? Check the appropriate box: Type of project (required):
1. NI I am a /
with employer 0 4. El am a general contractor and I
* have hired the sub - contractors 6. ❑ New construction
employees (full and/or part- time).
2. 1.:1 I am a sole proprietor or partner - listed on the attached sheet. 7. 11] Remodeling
These sub - contractors have
ship and have no employees 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. El Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.0 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. ❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t 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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ?erg LESS / iJ S U(Z AN CLr"
Policy # or Self -ins. Lic. #: 4 /4 S6 sis Expiration Date: 7 Vzoi,
Job Site Address: 6:2 1 Ly LAME City/State /Zip: A OK m7 t
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone #:
- Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
J
SECTION:8 CONSTR SERVICES
Y
8.1 Licensed Construction Supervisor: r ,, Not Applicable ❑
Name of License Holder : / )o U q�aS 6 • L� /9)4 j e 9 ` vo/
License Number
75 -J Rf is S 6Pt ) y Al 4 - - zt7/ Z
Address Expiration Date
(/'CnCk1t
4/ .5 - yb 7 7 7/
Signature Telephone
4 '11' "$fi e teTiqr:117 .::7 4r,` . 4 ' -V Not Applicable ❑
g a'N FAFrn eitS S&Fp L i 6 o y5 oti
Company Name Registration Number
--/ 7/ 57 E /NAB() 3761) YY1 A o/3 3 7 7 z9'- zo/ st
Address Expiration Date
yip)
Tel phone & y r ' 3 u
.stdristini10:t41/ORKERS,!,,COMPEN§ATIONINSIIRANCEAFFIDAVITAM;O:L c~1
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 ❑
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
•
J
. {
SECTION 5- DESCRIPTION OF PROPOSED WORK `(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [p Siding ID] Other
Brief Descriptiai of Prop /d , / /'�
Work: 1r jC / A f �� / t !� l 0 Sf /v
Alteration of existing bedroom Yes ". No Adding new bedroom Yes \ No ,
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
. `e ause aod�i�ddi #i'on a:ecisti;nct . ousin4 comii e'te . h�R:folloaiuiq:
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 .
I. Septic Tank City Sewer Private well City water Supply
SECTION Ta OWNER AUTHORIZATION -,TQ B COMP ETE� u WHEN
`. OWNERS AGENT OR CONT'' CTOR APPLIE F • J ' • ING PERMIT " - ,,
e , as Owner of the subject
property
hereby authorize ei/tARis k e 'v'N Fcti ✓" 1 - S
to act on my behalf, in all matters relative to w r a thorized by this building permit plica
Signature of Own Date
1D 0 tiq/ t3 6. A4c-t_ , as Owner /Authorized
Agent hereby declare that the statements and nT formation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
°clicks 6"• t Ph) et:
Print Name
39 /1
Sig ature of Owner /Agent Date
'"4/
■
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomp to Information
il f
Existing Proposed Required b La k ing ) i
This column to be filled in by.,,, ' ,,,
Building Department
.,..:..; . ....
Lot Size 1 I 1 {
i . Frontage , : ' .
Setbacks Front 1 1
M i 3 1 E :.
Side L:E t R: L:i . 1 R:
Rear 1 ( = I 1
Building Height i I 1 I
Bldg. Square Footage 1 I% 7-1 I I
i
Open Space Footage % {
(Lot area minus bldg & paved i s = 1 1
parking) r-
# of Parking Spaces ? I
Fill: i __. ._.. _ 1 , ____ . _ __.__ _ :
I
(volume & Location) I 1
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW ® YES 0
IF YES, date issued: I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book 1 Pagel and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 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 , Date Issued: j
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: [
t
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: 1 1
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.
52 EMILY LN BP- 2012 -0648
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18 - 033 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit # BP- 2012 -0648
Project # JS- 2012- 001116
Est. Cost: $4200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BERNARDSTON FARMERS SUPPLY 99401
Lot Size(sq. ft.): 46173.60 Owner: EDMUNDS PATRICK W & MARIE TREMBLAY
Zoning: RR(100) //RI /WP Applicant: EDMUNDS PATRICK W & MARIE TREMBLAY
AT: 52 EMILY LN
Applicant Address: Phone: Insurance:
52 EMILY LN WC
NORTHAMPTONMAO1060 ISSUED ON:1/11/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL VERMONT CASTING FIREPLACE
INSERT
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 1/11/2012 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner