29-131 HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 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 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
The Commonwealth of !Ilassachucsetts
� 7 =
= Department of L;t dccstria Accidents
O of lnves y ations
_ - 600 It ashina ton Street
Boston, A 02111
www.mass.;oti /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
Anaiicant Information PIease Print Leaibly
Name i Business /Orzanization/Individual : ���, . QAde
Address: Pc 7 / 1 `
Ci ty /State /Zip: 1 Pe4. 1 /4 . 0l 0 Phone #: TJ3 51?
Are you an employer? Check the appropriate box: Type of project (required):
4. 1 am a general contractor and I I
1. 11] I am a employer with 6. ❑ New construction (full and/or part-time).* have hired the sub contractors
2 I am a sole proprietor or partner- listed on the attached sheet. ❑ Remodel my
ship and have no employees These sub - contractors have 8. C Demolition
I employees and have workers'
working for me in any capacity. 9. ❑Building addition
3. L o workers' comp. insurance comp. insurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [ workers' comp. o ' right of exemption per MGL
1 ,
_ ❑ Roof repairs .
��
insurance required.] ' c. 152, § 1(4), and we have no 13 , Other „
employees. [No workers' S'
I comp. insurance required.]
Any applicant that checks box #1 must also fill out the section below showing their workers' coniensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors must submit a new affidavit indicatir..g such
} Conn - actors that check this box must attached an additional sheet showine the name of the sub - contactors and sate whether or not those entities have
employees. lithe sub - contractors have ernployees, 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.
Inturwnr.= fmmpnv N
Policy 1 or Seif -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 crininaI penalties of a
fine up to 81,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 3250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLz for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury than the information provided above is true and correct.
Sionature: A.,, / 1 Date: T • . r
Phone Or ,' - ,ra
I
I 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. Buiidina Department 3. City Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
I
i Contact Person: Phone ,,
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su rrs r: 1 Not Applicable ❑
Name of License Helder : 4 / 4
,s
License llum r
/�t5 - Zees /111.00 / "
ddr Expiration Date
;ignae Telephone
t. Registered Hoene Imoravernent Con ractar a Not Applicable ❑
7 :omoanv Name � / Registratio Nu ber
/'701cc.. �J8- / ehfr olosS 6 3G of
.ddress Expiration ate
Telephone S :S'';3 c)
ECTION 1:0- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MMG L. c. 152, §-25C(64) I
Porkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit..
gned Affidavit Attached Yes 4 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 -vear 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 hermit
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 U Addition I 1 Replacement Windows Alteration(s) J 1 / Roofing I i
Or Doors
Accessory Bldg. n Demolition 0 New Signs [C] Decks [Q Siding [ Other [Q]
Beef Description of Proposed / 7/ / �� /
Alteration cf existing bedroom Yes ✓ No i Adding new bedroom Yes 7 No
Attached Narrative Renovating unfinished basement Yes y/ No
Plans Attached Roll - Sheet
Sa. If Neii house and or addition td ezistinq fho isina. dorm fete thefoflowinc:
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 Woedstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type cf construction
i. Is construction within 100 ff. 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 Ne .
I. Septic Tank City Sewer Private well City water Supply
I SECTION 7a -OWNER AUTHORIZATION - TO SE COMP €ELt1J WHEN _
OWNERS AGENT OR NT C LS
' CORATOR:APPIE- R
FOBUIDN
LIG. PERMIT
I, _ . os as Owner of the subject
property hereby authorize £ '' ' A' �� Je`
to act on my behalf, in all matt rs relative tiwork authorized by this building permit application.
Signature of Owner . Date
I ( . 1 I 24i-e , as Owner /Authorized
Agent hereby declare that th statements rid information on the foregoing application are true and accurate, to the best of my krowiedge
and belief.
Signed and the pains and penalties of perjury.
,...2� i C r4,R‘.lC�
Print Nam-
:3,cnature .f Ow- r F.GEnt `e
t
Section 4. ZONING All information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Re by Zoning
Th is col quired um to be Of in by
Building Department
Lot Size �_„_ __ ..._ .,.._:.. w _ .._.„ i __.
Frontage __.._:, _._...._:__�_ �.___.. _.._,_.. ___ :
Setbacks Front
Side
Rear ___
Building Height *.._
Bldg. Square Footage .—
Open Space Footage % uwh .
(Lot area minus bldg Sc paved
parlcne)
# of Parking Spaces -
Fill:
(volume & Location) -- _
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds?
NO (3 DONT KNOW (3 YES 0
IF YES: enter Book Page, and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES (3 NO
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, grading, excavation, or filling) over 1 acre or is it part of a conumon plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm WaterManagement Permit from the DPW is required.
Department use only
City of Northampton Status of Permi
Building Department Curb Cu Drive Perr
212 212 /lain Street SewertSepticAvailabitity
"G > Room 100 WaterfWeltAvailability
\ r � NortR MA 01060 Two Sets' of Sfruc ural Plans
y phone 41$7 1240 F ax 413 -587 -1272 Plot/Site Plans
Other Specify
APPLIC TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - ` MATION 1
1.1 Property Address: This section to be completed by office
Map Lot Unit
Zone Overlay District
Elrn St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 1
2.1 Owner of Recor /d: �' �j 4 -
Name (Print) ` � Current Mailin Address:
C S:? LG Telephone
Sig:etr;
2.2 Autho ed Agent:
/'fzwe, /-- 1Ps /y�: 01 oC3
Name (Pn ) Current Mailing Address:
Signature Telephone
SECTION 3 TIMATED CONSTRUCTION. COSTS
Item Estimated Cost (Dollars) to be Official Use Only I
I completed by permit aoolicant
1. Building '6. el) I Permit Fee
2. Electrical 7 (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)
Check'Number (p XD �S
This Section For OfficiahUse Only
Date
Building Permit Number Issued:
Signature:
Building, Commissioner /Inspeeto�ot Buildings
Date
•
BP- 2008 -1036
GIS 8: COMMONWEALTH OF MASSACHUSETTS
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- 2008 -1036
Project # JS- 2008 - 001538
Est. Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Craig Marney 102112
Lot Size(s2 ft): 9365.40 Owner: SMITH DOUGLAS M
Zoning: URA Applicant: Craig Marney
AT: 33 ALAMO CT
Applicant Address: Phone: Insurance:
P 0 Box 128 (413) 586 -5512
LEEDSMA01053 ISSUED ON:5/19/2008 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 5/19/2008 0:00:00 $25.004964
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo