38D-031 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 constmction 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/footines (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
•ermits 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
understand the above.
(H, r / 1n twr. ature equesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date 5 F
Address of work A /
location / QcJ 1/-
MrP47' jV a /0 60
,
The Commonwealth of .tifassachusetts
Department of Accidents .
t. =,:jej ) ...■ CA Office of Investigations .
600 Washington Street
Boston, MA 02111
www.mass.gov/dia .
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeiblv
Name (Business/Organiza' lionAndividu2D: F4+rry • Dc„..9701 ----
/
• Address: 7 1 , /),„ A ve_ .. - - •
City/State/Zip: illarlLy? / hr - ,#2J fi woohorte.#: V/3 - 582.-699 )..._
ie
Are you an employer? Check the appropriate box: • • Type of project (required): /
1.0 I am a employer with 4. 0 I am a general contractor and 1 . 0 New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet: 7. R-emodeling
2. 0 I am a sole proprietor or partner-
These sub-contractors have 8. Demolition
• ship and have no. .>loyees
enA).loyees and have workers . . -
working for me m any capacity. 9. EjBuildMg a4di1ion
[No workers' comp. insurance
required]
5. 0 We are a corporation and its 10ArElectdcal repairs or additions
3 11 :2 •
. I am a homeowner doing all work officers have‘ercised their . 454 Pluming repairs or additions
b
i 1
myself [No workers' comp. right of exemption per MGL
120 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp - Insurance required-1 .
*Any applicant that checks box #1 must also fill out die section below showing theirworlosts' • compensation policy infonnation.
t Homeowners who submit this affidavit indicating they are doing all wo and then hire outside contractors must submit anew 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-contractorsltave employees, they must providetheir worlcers' conm. policy nu:mber. -
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. -
• •
Insurance Company Nan=
- •
Policy # or Self-ins Lic. #: Expiration Date:
. .
Job She Address: City/Stair/Zip:*
Attach a copy of the workers' compensation policy declaration Pagn(showing the policy numb er and expiration date).
Failure to secure coverage . as required under Sectiii25A Of MGL c 152 can lead th the iinpOsitian of iiimina,1 penalties of a
fine up to S1,500.00 and/or one-year imprisonme4 as well as civil penalties in the form of; STOP wcgucaRDER and a fine
of up to S250.00 a clay again.st the violator. Be advised that a copy of this statement may be forwarde d io the Office of
&falai of the DLCfOriltli111'aiki coverage verification
_ I dd hereby_certift under, , ains-and , enalties of p -4 ' , that the informationprovid id ibov • , , 'met. _
,o1Ili." 4(
,.
w . 4 1 • tare: .Aib I • -I /0..... D IZ ' • C.5 ,
--
Phone ii: r'— 2?;- -I ao - • - •
Official use only. Do not write in this drat, 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. ElectricalInspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #: f- • - .
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Reuistered Home Improvement Contractor: Not Applicable ❑
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 ❑
11. - Home Owner Exemption
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 10835.1.
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
Northampton Ordinances, State and Loc. Zonins Laws and State of ssachusetts General Laws Annotated.
Homeowner Signature 7:f07
•
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 [D] Decks [[_] Siding [0] Other [0]
Brief Description of Proposed_ � // �� / J
Work: t trip ioo ri t) ofic '/DGI eLn fe 4,1 % �l o ��/ polar — Tai 1(1 5 ffr vnar'
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
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 BUILDING PERMIT
l , 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
4 r'r _DC le , as Owner /Authorized
Agent hereby decllre that the st and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perju .
Print Name / ,
Signatu - -r /Agent 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 L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
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 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW 0 YES Q
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
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 Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
, Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
r Room 100 Water/Well Availability
- a Northampton, MA 01060 Two Sets of Structural Plans
I"\ phone'41 7 -1240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify
V `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
el 1 64,i 101/C Map Lot Unit
/ v //an? &bh MA C/a 6 0 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: 1� � / ,�� 1 ,
Arr Dm e/6 7 0 g oa( 5 ! % �l ,Or) / 't4 cr0
Name (Print) Current Mailing Address:
..e:::7 � Telephone V
Signature G . 7 l ` 3 -- 7 $� ^ v 9'9102--
2.2 Authorized Anent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by penxit applicant
1. Building 17;660 a 000, (a) Building Permit Fee
2. Electrical / Pik 4co, �e) (b) Estimaed Total Cosof
62 SS Construction from (6)
3. Plumbing / e5.5 . /A4 A , f / 6100,G(2.) Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection a
6. Total = (1 + 2 + 3 + 4 + 5) ,6; 000, 0 0'- y , co Check Number /xii l�I 03
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0977
APPLICANT /CONTACT PERSON DAGGETT BARRY
ADDRESS/PHONE P 0 BOX 45 NORTHAMPTON (413) 582 -6992 Q
PROPERTY LOCATION 9 HARLOW AVE
MAP 38D PARCEL 031 001 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 !�
Typeof Construction: RENOVATE BATHROOM (TUB,TOILET & VANITY)
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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved 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
4 0 - 3 - 1-4~-- -- ---- P c751/0
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.
•
BP- 2010 -0977
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:.Block: 38D - 031 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 -0977
Project # JS- 2010- 001443
Est. Cost: $4000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 5401.44 Owner: DAGGETT BARRY
Zoning: URB(100)/ Applicant: DAGGETT BARRY
AT: 9 HARLOW AVE
Applicant Address: Phone: Insurance:
P 0 BOX 45 (413) 582 -6992 0
NORTHAMPTONMA01061 ISSUED ON :5 /5/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK: RENOVATE BATHROOM (TUB,TOILET &
VANITY)
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 5/5/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo