38B-148 6
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 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 buil ding permit.issued,_and_ 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
Q se- --, understand the above.
(Home owner /resident's signature reques'ing exemption)
/ I will call to schedule all required building inspections necessary for the building permit
V issued to me.
s.
Address of work location
1,D ®r1A.-G ,., QL 0 0 o t6,
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 =ffi i . Office of Investigations
. 1 .
' �� 600 Washington Street
[° i
r — Boston, MA 02111
„� www.massgov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print LegibIv
Name ( Business /Organiiation/Individual):
Address: -
City /State/Zip: Phone #:
,.
Are you an employer? Check the appropriate box: Type of project (required):
�
1. I am a employer with 4.. 0 I am a general contractor and I 6. ID 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. 0 Remodelin g;
ship And have. no. , - nployees These sub - contractors have. 8. ❑ Demolition
an capacity. employees and have workers'
working for me in
Y P ty. 9. E Building addition
[No workers' comp. insurance comp._ insurance
required.] ed 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I -am a-hdoing-dog work o cerslaa — I-I. Q Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 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 street 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.
Iam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
formation.
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 $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 un to $250.00 a day against the violator. .e advised that a copy of this statement may he forwarded to the Offii:r 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 #:
O ff i c i a l u s e o n l y . Do not w r i t e iii t h u a r e a , ti be completed by cuy or town ofcraL
City or Town.: Permit/License #__
Issuing Authority (circle one):
- i. Boa -rd of Health 2. Building Department 3. City/Town Clerk 4. EIectrical 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.: Reciistered. FFome .9mpraver;ieriGiantraoi�... ., .. > m. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
I
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 ❑
The_current_exemption for "homeowners" was extended to include Owner 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, in is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ nr 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 referenceto 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
o ampton . r i finances; ' a e r , w - tts-C eneral•=f:a-ws- Annotated.
Homeowner Signature
4
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 [O] Decks ED Siding [O] Other [o]
'rief Description of Proposed
Work: F • dgi /% //', /2/E p.9/^. G c/tAel74 z, 1 t? /evz P //' -/sA/
Alteration of existing bedroom Yes No Adding new bedroom Yes ° No
Attached Narrative Renovating unfinished basement Yes _
Plans Attached Roll - Sheet
sa 'If New hotisevart ":or add i t to existing 4 6atimilke the fallowing:
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 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR DUILDING PERMIT
1, , 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
, as Owner /Authorized
Agent hereby declare that the statements and information on the regoing application are true and accurate, to the best of my knowledge
and belief.
/ 'Signed under the pains and penalties of perjury. (�
Print Nam / 1
C` 1 01 1 _ - - - --
Signature of Owner /Age Date
Section 4. ZONING All Information 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
Setbacks Front
Side
Rear
Building Height
Bldg. Square Footage p i
Open Space Footage •. _._.,
(Lot area minus bldg & paved
parking)
# 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
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Pagel i and /or Document ft
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 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D.` — f=i`ere any propose c anges to or a Tt ons o signs intenaedfor 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 common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
4
r
�` , ,, ;, •; .�. ED, } t 3I! r f y " -:
--' City of Northampton a1 � �
Buit Department Gtr# +9rt e�y l�;
V 4,47 e s ,. t l .try �� _ i
r 2 Z 12 in Street Se itart
C -, .,,s Roo 100 x e 9t � g
North pion, MA 01060 ¢ a ` � i; t: tip.. �M
,, phone 41a -'587 -1240 Fax 413- 587 -1272 e &,A t ti l ,,,
6 th pe ' -gs , x-x ,., 4 2 3r
• ,, • . ,ta„.„ -+ �s�17 tea,. . , ,-,- ` e ,., I : . r ... * •.a wg _9..'
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
I
SECTION 1 SITE INFORMATION
1.1 Property Address:
This section to be completed by office
Li- C 21- '/7 /3 (/..' .of i'� Map Lot Unit
,f/c , iH' /'/ -e---. ` "'S
� Zane Overlay District
Elm-St CB District
SECTION 2`- PROPERTY OWNERSHIP /AUTHORIZED AGENT
1 Owner of Record: 1•J0C-ki,rw■-i\*D4V\
,-� v. .) cr c _\ -0 1 e ? - _ ► ',„ ` u` S i-.2, !"■ U) b elf
Name (P ' Current Mailing A..1 -
`"`/ Telephone i j - ,
Signature __
2.2 Authorized Agent: i i OCT 2009
Name (Print) Current Mailing I4ddres_ _ _..
Signature Telephone --- — ._,_
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
j Budding (a) Building `Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6) ,//76
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number 55
This Section For ifficial: Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
I
/ '� ,
��'
FOR �l/ l %/ Gtr ...
�� A M
M.
DATE f / ' 7 TIME P. .
OF.
PH / 3 - .. - — == B R 7 - `r
_ :::A REAC OD E - - -- N UMBE '....EKIE
ca FAX
❑M OBI LE 3 ? Z d 3 . �/r - a
• AR CODE NU MBE R , TIMI3 CALL
,�..�;�w n .� a.�:?mz'r�aw�,�.... `�-�' �"� �i , x e ;� .�z � � � �,r�r ,�< ., •
MESSAGE /
•
a"lj - _ -,9 7- f F C ._-
' E
c �LV 's
2 � cwt 'O.. =, 7 L- /rte /a
G� 51 °- 3 i�- 3 ?- 5
`SIGNED = ��u
FORM 30025
MADE IN U.S.A
File # BP- 2010 -0478
APPLICANT /CONTACT PERSON JORDAN -REYES EUGENE F & SUZANNAH E JORDAN -REYES
ADDRESS/PHONE 47 COLUMBUS AVE NORTHAMPTON (413) 320 -6432 0
PROPERTY LOCATION 47 COLUMBUS AVE
MAP 38B PARCEL 148 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 053--
�J
Typeof Construction: REPAIR ROOF & REPAIR EXTERIOR ROT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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 Permit DPW Storm Water Management
Demolition Delay
Signature of rig 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.
1 BP- 2010 -0478
GIS 4 COMMONWEALTH OF MASSACHUSETTS
148 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- 2010 -0478
Project # JS- 2010- 000659
Est. Cost: $6000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
t sc (%coup: Homeowner as Contractor
Lot Size(sq. ft.): 5749.92 Owner: JORDAN -REYES EUGENE F & SUZANNAH E JORDAN -REYES
Zoning: URB(100)/ Applicant: JORDAN -REYES EUGENE F & SUZANNAH E JORDAN -
REYES
AT: 47 COLUMBUS AVE
Applicant Address: Phone: Insurance:
47 COLUMBUS AVE (413) 320 -6432 ()
NORTHAMPTONMAO1060 ISSUED ON:11/5/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR ROOF & REPAIR EXTERIOR ROT
POST THIS CARD SO IT 1S 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 11/5/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo