38B-244 w ,
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
_rev atinns The inspection process_equir_es 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
--- ---- -permit-s- in- conj the - building .permit..issued,_ 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.
—Hate
Address of work
location
x 4 .`
The Commonwealth of Massachusetts
Department of Industrial Accidents '
- ri Office of Investigations •
, = ,
r -
. v - 1 600 Washington Street
r
—n11._ Boston, MA 02111
te _
■■ 5 ,: , www.rnass gov /dig
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
A. olicant Information Please Print L iblv
Name (Business/Organizatio. . divid . ‘ r -0 L - )c...- ,,
Address: V U C`;,- 1 ,
City /State/Zip: (�eA ot P hone.: 7 �
Are you an employer? Check the appropriate box: Type of project (required): 1'
1.0 I am a employer with 4.. I am a general contractor and I 6. 0 New construction
e ees (full and/or part- time).* have hired the sub- contractors
listed on the attached sheet 7. 0
2. am a sole proprietor or partner- Remodeling
ship anti have. no ^•Tloy ees These sub - contractors have. 8. ❑ Dem.o;ition
an capacity. employees and have workers'
working for me in
Y P ty 9. 0 Building addition
[No workers' com11 insurance comp. ;assurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
_officers have` i
,eercsed their 1-1: m r
3.0 I- am- a�orneo-waer ti�� aIl werk- - - - -�- g repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. Roof repairs
C. 152, §1(4), insurance required.] 1 4 and we have no § (� 13. Other
employees. [No workers'
comp. insurance required}
Any applicant -that checks box #1 m also fill out the section below showing their workers' compensation policy infomnstion.
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
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 up to $250.00 a day against the violator; Ise advised that a copy of this statement may be forwarded to the Office of
Investinations of the DIA for insurance coverage verification.
I do hereby_ certify un • y • pains and penalties of perjury that the information provided - above_a_truenndcorr-ect._..__ _
Signs e: �,- /.� Date: 1 t' j a'r
Phone #: Hi 3 3e1 7Sf 'y1
Official use only. Do not write in this area, — to be con3pleted by city or town officiaL
City or Towne 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 #:
a
,
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
- Le,— JOG b
Name of License Holder : ,
-License-Number - -- - - --
? e,k. H 1— .( / A C 1 L i — 20/.1_,
Ad Expiration Date
7/°- cir y 1-6c,
S' nature : Telephone
9_.12 istered H ome Improventent<Gontractor „ , " :
. . �::- I Not Applicable ❑
,�` J L /`f 27;?Ft
Company Name C)'-'6)\ A „ n Registration Number
Address p Ex irati D ate
�/ j
Telephone r/3 7E' t d "
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 pe ' .
Signed Affidavit Attached Yes No ❑
.I1 i QQwner ption
T_he_ 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 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
Oft am r finances, a e •n• • • . •_ + w - ° 1 _ •
. efts- General- Laws - Annotated.
Homeowner Signature
0
,
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
______--
New House 0 Addition ❑ Replacement Windows Alteration(s) E Roofing I
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[:] Siding [O] Other [O]
Brief Description of Proposed
Work: ' \ "f �— Sti., -4 Lz. V d 36 y i A .e a , .. 4 t,:, ( 5
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If NeWhousiend or addition to erinsthia "tiousincv conipfete -the follaw>Inq:
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 - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 1 7 A J2 ja t er n , as Owner of the subject
property F
hereby authorize 'D �-•V\ MI VI R. te
r.
to act on my beh f, • all matters relative t work authorized by this building permit ppli ation.
_ ppli
9
Signature of Owner Date
1, J t-h" /`-'k.1 ✓1 a (M. , as Owner /Authorized
Agent hereby declare hat the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed unde the pains and penalties of perjury. AAAA-7
Print Na -`
lit s ot_ iA / 2 - /9-41 ___
Signature of Owner /Agent Date
� � e
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:,
Rear
Building Height
Bldg. Square Footage _' "'" ' °_ %
Open Space Footage
(Lot area minus bldg & paved
puking)
# 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 0 DONT KNOW 0 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 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D v r/ e tW`e're an ro osed chap es to or add ons o si ris intended foF t ro ert YES 0 NO
YP P g g P P Y?
IF YES, describe size, type and location:
E. WIII 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.
ft
City of Northampton S PeYrrf
Building Department u c D wa ys 1
� �� 212 Main Street Se rer�a 1 atlal3r ���
,� ,, r . Rpom 100 c i� ab 440 01n60 „,,,.. ,, r �� s
4. p ho � tie 413 - �87 t 40 Fax 413 - 587 -1272 a r s ,M "� t
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
This section to be completed by office
1.1 Property Address:
OZ 5 S c--,,,.,11A si- Map Lot Unit
'Zone Overlay District
EIm St ° 'District CB District
SECTION 2 -- PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
44.0-2--. 1 v\ 29 Ve:A v‘ s+ Jo uit KA4.6 /V( a_.
Name (Print) Current Mailing A r ccr _ ... _- -, 7
Telephone _ 9 _ 2 9 I
Signature
2.2 Authorized Agent:
j v1 A . LA (1 list &Irv. r a • Bcy k 3 ..00y-ket
Name (Print) 7 Current Mailing Address:
...L.4 .4.4.11. / _. Lft 3 - SAS 2 7 z Z.
Signature / Telephone
SECTION 3 EST CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 2 (AU " (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
_ Construction from (6)
3. Plumbing Bui Perm Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) C heck Number /1 / ,0,55-__
Th Sect F or Offic Use Only
Permit Number: I
Date
Building Issued:
Signature:
Building Commissioner /Inspector of Buildings'; Date
�-
118 ., t; H: BP- 2010 -0594
GIS #: COMMONWEALTH OF MASSACHUSETTS
ktAiidliWmit 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 -0594
Proiect # JS- 2010 - 000866
Est. Cost: $8200.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY LUCE 100515
Lot S17e(sq. ft.): 8407.08 Owner: HEIN HILDE C/O JENNY MIRIAM
Zoning: URB(100)/ Applicant: TIMOTHY LUCE
AT: 228 SOUTH ST
Applicant Address: Phone: Insurance:
127 Audobon rd (413) 387 -9800
LEEDSMA01053 ISSUED ON:12/11/2009 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 12/11/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo