38B-103 efr
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- i-n-conjunction_to the bull n� ng..pennitissued,_ 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.
Address of work
location
Mk
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 ......v.,.._ P Office of Investig,ations •
;�� . 600 Washington Street
1 Boston, MA 02111
,;,� www.mass.gov /dia •
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print LegibIv
Name ( Business / Organization /Individual) TAA Keel c — Gt_-
Address: 1 1,2 9 ,7 rgeL.d -r-4,° ' .
City /State /Zip: 6 e & 1 RP a i t Yhoae #: 1 113 ` ®O 7 1
Are u an employer? Check the appropriate box: Type of project (required):
1. I am a Io. er with 4 _ I am a general contractor and I
Y 6. ❑New construction
employees (full and/or part- time).* have hired the sub - contractors
2.0 I am a sole proprietor or partner- listed 7. 0 Remodelirsg
shill and have. no . 'i 1oyees T7iese sub - contractors on theattached have. sheet. 8_ [� Demol on
capacity. employees and have workers'
working for me in any p ty. t
(Na 9. 0 Building addition
workers' comp. c insurance.
mp. insurance
required] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
officers_hav ercised_their i i Plumb_ a
3. 0 F am aTiomeoner dfl a$work — — 0 g 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=
1 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: ftt V l 1..5 -
t , /
Policy # or Self -ins. Lic. #: ' �q k U E, O ?(3 G 7 - 6 - r - Expiration Date: g'iT
Job Site Address: ( MO A. roe-> � - ' VI of k, P th gCity /State /Zip V0 , 1 ko /'1 / r ` `9- "
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 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. 15e advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certify under the pains ; and penalties of perjury that the izzforznation provided _above_i .true anuLcorrect ___ _
Signature _exSZ3� . • --- patty; /. : f
/
Phone #: `- 0 3 r i r 15 - 00 `) -1
Official use only. DO riot Write in this area, — tube coin -feted by city lvn offu ia1
II
City or Town: Permit/License #_
Issu ing thoy (circle one):
I. B oard Au of Heal 2. Building Department 3. City/Town Clerk 4: Electrical Inspector 5. Plumbing Inspector
6. Other r
Contact Person: Phone #:
.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable � ❑
Name of License Holder : ! 7 6 t r U ,r , 7 I �v
License Number
,,. < e , r`X 5 -,> — t l
Addrek f - Expiration Date
Signatu Telephone
9. Registered. Home: hnprovementContractor° .:w, r Not Applicable ❑
Company Name Registration Number
Address 929 1
ee s�j Expiration Date
t+' 71 n L'd T . Telephone e //3. 775' e. rem -R4 th) v v i 6t.) q / J
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 off No ❑
erillOtiOn-
The_current_exemption for "homeowners " 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, 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
l�ortl°iamp on r in nce at an l axe i . • 1 . • • • e s-Gener-ai.T aws- Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [C] Siding [❑J Other [❑]
Brief Description of Proposed / /
Work: e MA/l �N"?.S.�IZ4' fool- C).»1d at d � /
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative . Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa_: If..Nevi } iousltii k.aompiete: the' .fakiWindj
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 • Ta BE C' ®MPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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
(L , as Owner /thorized
A 9 en ereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and ief.
Signed under the pains and penalties of perjury.
-at ((i .. sZe .roLL
ame
\ Signature of Owner /Agent Lc_
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 L R__..._._ L:,___ .: R:
Rear ",_, w_ _.
Building Height 'M'
Bldg. Square Footage f----7
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill: r .��a�
li
F
(volume & Location)
' A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW ei YES
IF YES, date issued:
IF YES: Was the permit recorded at the Reg try of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book Pager ? and /or Document if
B. Does the site contain a brook, body of water or wetlands? NO 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:
C. Do any signs exist on the property? YES 0 NO e r
IF YES, describe size, type and location:
___ ___- --_ -. - `ire tFiere any proposed c anges to or a Uo o signs`inten ed for the` property ? YES 0 NO e
IF YES, describe size, type and location: �
E. Will the construction activity disturb (clearing, grading, exc vation, 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.
•
i �0epartrrietitiise iiti r
City of Northampton Stawi af`t'errtit
Building Department 4titYDrlv 0
Cut rirtit
212 Main Street S e c il k vail br ly'� 4 n
Room 100 ; rJ to a i nti ' k �` A
Northampton, MA 01060 , e " , °°4� � r 1 r fi 4. s ;
phone 413- 587 -1240 Fax 413- 587 -1272 s � ,ot -
,�' mi l
Cl `ei S4e s t' � . ,.s✓- s Av`"g
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMIL 7LLING
/�
SECTION 1 -SITE INFORMATION �f /
1.1 Property Address:
This section o, e ted by office' '' \
5'
t)i1 - Map �, / ri' Un ity
Ndr1, � LA. Zone ' `yd' Overl is•rict_ .
EImSt- District CB.District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
fi r .
2.1 Owner of Record: ..,.
Name (Print) Current Mailing Address:
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
pleted by permit applicant
1. Building Cf�5 ''� (a) Building Permit Fee
2. Electrical / (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
T his Section Fo Official Use Only
Date
Building Permit Number. Issued:
Signature: •
Buiilding Commissioner /inspector of Buildings Date
a \
BP- 2010 -0283
GIS #: 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- 2010 -0283
Project # JS- 2010- 000368
Est. Cost: $4250.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: READE ROOFING 87965
Lot Size(sq. ft.): 7492.32 Owner: BOYLE WILLIAM F & PENELOPE
Zoning: URB(100)/ Applicant: READE ROOFING
AT: 11 MUNROE ST
Applicant Address: Phone: Insurance:
429 DEERFIELD ST (413) 775 -0071
GREENFIELDMA01301 ISSUED ON:9/15/2009 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 9/15/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo