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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
jermits 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 Massachusetts
Department of Indus Accidents
--7
=sipel=1: - Office of Investigations
="41. 600 Washington Street
z.....7.1:F=.• z
Boston, MA 02111 .
f... =....-3,
v.,„,...,,;-:-..-- -
' www.mass crov/dia .
....
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers -
Applicant Information Please Print Leeiblv
Name pusinessiorganizzionadiviemo: ,
Address:
City/State/Zip: .. Phone#:
Are you an employer? Check the appropriate box: Type Of project (required): 1'
1.0 I am a employer with 4. El I am a general contractor and I
6. 0 New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet 7. Remodeling
I am a sole proprietor or parmer-
These sub-contractors have.
" and have no :lloyees 8. Demolition
employees and have workers'
working for me in any capacity. 9 '0Buildini additiOn
[No workers' comp. insurance _ camp.iusurance.T.:
.Ei required.] .. 5. 0 We are a corporation and its 10 Electrical repairs or additions
3. 0 I am a homeowner doing all work officers have 4xercised their
r 11.1E Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL
12.0 ' • .f repairs .
insurance required.] t c. 152, §1(4), and we have no ( 4--•
employees. [No workers' 13.gkOther I IA c l 3\a, Vc.51--
comp. insurance required.]
*Any applicant that checks box #1 must aLso fill out the section below showing their wor/cas' compensation policy information.
t Homeowners who submit this affidaVit imEcating they are doing all week 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-connactors and staXe whether or not those min 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 andjob site
information.
Insurance Company Name:
• •
Policy # or Self-ins Lic. #: Expiration Date:
Job Site Address: City/Stafr/Zip:"
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage is required under Sectiar 25A 'OfNIGL c. 152 can lead to the iinpositibri of Miming Penalties of a
fine up to 51,500.00 ancVor one-year imprisonment, as well as civil penalties in the form of a STOP WOF,S-oRDER. and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Et DIA for'insurance coverage viiili
i o kr d e eertrbY un pains and penalties of perjury that the En' format:to' n provzdetl' _aboveivnze_and.cort. rec _
Er fc)
-
---- --: k .,. ,
Sienature: \ Dat : 41 Z 6 ( ( ■ •
Phone it: 4 ( )7 - (.-9 c. -C 557 - - •
Official use only. Do not write in this area, to be completed by city or townOfficiaL
City or Town Permit/License #
:
Issuing Authority (circle one): ' -
:1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical juspector 5. Plumbing Inspector
6. Other
Contact Person: '
Phone #:
SECTION 8 -= CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : �(' 15 /1.t�lii/1. �� G ' ' 1 5
License Number
2 7 .,/L4 it tb.q t r re-c5( • L ki ' .mil • 41q/ 7 13
Address Expirati n Date
C-7. — 6q5 — , fi g 7
Signat Telephone
94:Retilster"edHo litiiiiiiiiiiiiiiit taiiittiffillitiiiifrMiglidgali C ontract or Not Applicable ❑
�s s
141
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 ❑
The current exemption for "homeowners" was extended to include Owner - occupied Dwellines 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 buildine 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 D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [o]
Brief Description of Pro • • - • - Nk L G .- Y' V' i Zc. i } " t'∎ 'e r
Work: "� -.-,: _ _ __. � -
w
Alteration of existing bedroom Yes No Adding new bedroom Yes O No
Attached Narrative Renovating unfinished basement Yes �
Plans Attached Roll - Sheet
ear if i • a r..t' c 1 i t n o ', : us t Oiil` i tafh+ Ilo na:
a. Use of building : One Family Two Famil Other
b. Number of rooms in each family unit: Number of Bathrooks
c. Is there a garage attache
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 la - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, I !/‘ e - cam, , ' 6._ as t' ` i k tev\ , as Owner of the subject
property
hereby authorize 1( ---.1 1 (1 lV ` S b d
% --
to act on my behalf, in all matters relative to work authorized by this building permit application. •
!
Signature of Owner Date
1, -( 1 1(�(^N�G, 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 b lief.
Signe under the a'ns and penaltie of perjury.
V I S it E Z -t.v'X :
Print Name \ w
� r�' -' 4 •
Signature of Owner /Age" Date
,
. "7
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete nforrnati
Existing Proposed Re quired b nin ' W` 1 f
Th is column to y fillejn by # '
Building Depa
Lot Size .. ..,,,,,
Frontage 1 ' 1 _r
Setbacks Front i
Side Li = R: 1 L: 1 R:'
Rear 1 I 1 ,
Building Hei `�� ________
Bldg. Square Footage i % 1 r 1
Open Space Footage %
(Lot area minus bldg & paved s j i ...,
parking)
# of Parking Spaces 1 °------
Fi11: I ,
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 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
1 i I ; ,
IF YES: enter Book Page I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 6 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ,Date Issued:
C. Do any signs exist on the property? YES ® NO ��
IF YES, describe size, type and location: I r
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO s lit
IF YES, describe size, type and location: C
I
E. Will the construction activity disturb (clearing, grading, e - vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO fi'
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
fi
City of Northampton
VAt I° Building Department
212 Main Street ®� r
, Room 100
Northampton, MA 01060 L �., "
rte•. � � � � �� �
phone 413 - 587 -1240 Fax 413 - 587- 1272 sE
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
1.1 Property Address: This section to be completed by office
jatigEa A S OL) tt,. k" Map -Lot Unit
( i ? Zone , J' OvertayDrstnct
0 1 Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: II J
ex-)vc, �l� / ; ✓ite NSSttitu,�. SG1inti� (Al 1 )
Name (Print) <!! Current Mailing Address:
Telephone 5 4 _ 3 b
Signature 1 /
2.2 Authorized Agent:
e i b LA /t S c ( v I - • L0-ev r ,tic, .
Name ( nt) Current Mailing Address:
X 09 5 — (0 4 i 7
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building co O (a) Building Permit Fee
2. Electrical I i 0 00 (b) Estimated Total Cost of
Construction from (6)
3. Plumbing 1 0 0 0 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection t /
6. Total = (1 + 2 + 3 + 4 + 5)
7 0 n U Check N umber f i) �i!o
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP -2011 -0896 ,
APPLICANT /CONTACT PERSON KRIS THOMSON
ADDRESS/PHONE 257 MONTAGUE RD LEVERETT (413) 549 -1027 Q
PROPERTY LOCATION 134A SOUTH ST
MAP 38B PARCEL 084 000 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ea Fee Paid Typeof Construction: REMODEL HEN
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 084152
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
44......."e
Demolition Delay
Signature of Building 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.
134A SOUTH ST BP- 2011 -0896
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B - 084 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2011 -0896
Project # JS- 2011- 001455
Est. Cost: $7000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KRIS THOMSON 084152
Lot Size(sq. ft.): Owner: SISSMAN MICHAEL
Zoning: Applicant: KRIS THOMSON
AT: 134A SOUTH ST
Applicant Address: Phone: Insurance:
257 MONTAGUE RD (413) 549 -1027 0
L EV E RETTMA01054 ISSUED ON: 5 /4/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN
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 5/4/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner