38D-063 (2) 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 buildin ' 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_thebuild' erraitissued, 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.
Address of work
location
•
. The Commonwealth of Massachusetts
Department of Industrial Accidents
„...==,,..= : 4 � gt Office of Investigations •
• r �0 1; 600 Washington Street
_Te Z Boston, MA 02111
www.massgov /dia
-Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/PIumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): ri 1 \ JY p e ---,( i c�
Address: 3 / l ( , t _\ �r .
City /State/Zip: ± orP (4 e e \, 0■06O Phone. #: Z6 -) TS
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. New construction
employees (full and/or part- time).* have hired the sub - contractors � ,.,
I am a sole proprietor or partner- listed on the attached sheet. /- ' (J R�delin¢
ship and have no e. loyees These sub - contractors have. . g. 0 Dem l tion
for mein any capacity. employees and have workers'
working
Y P ty 9. ❑ Building addition
[No workers' comp. insurance - c insurance_
required] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I -am a- homeowner-- doing-all -work ce .have4xercised their —1-1-.0 Pluinbing 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. LJ Other
comp. insurance required}
*My 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 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.
/am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
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. lge advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the p ,4 ". . and fP r1 ry f p
and penalties o . e 'u that the information ravided_above_is1 ue audcvrrecL __- __ _
2
- Date. 7 Z _ ... / (-1
Signature_ - /e (
Phone #:
O jfc ia l use - only. D O no ite ill t a to be completed by city o r town officiaL
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other -
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su rvisor: Not Applicable ❑
Name of License Holder : ()5 (� C -S
License Numb r
I � (' ,/z � Z
Address Expiration D to
,,-) L /(0 -k
Signature Telephone
9.,Renietered:Homelm rotre menlContractor , x _ .:4, K .,5,24 ,.., <. Not Applicable ❑
e i 11 ( ? (_ j i 7 2 ?
Company Name Registration Number
1 tV-tt: ,� * 1 046 , I 1 1, I
Address Expirati n Date
Telephone32' 3
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 ❑
onie . e>r, k e i on
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, 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
� o amp on • r.lnances, a e . - — . _ 0 I • " ., , r, o i tts E eneral. 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 [D] Decks [C] Siding [O] Other [0]
Brief Descri,otion of Proposed) ; MUT
Work: Lf l 1 e haq%A r -, ) -�i� k36 \fv3i,LL-C r O D (61.ek IV he.) (1 IAA<A Y j veva kt.\.._
Alteration of existing bedroom Yes No Adding new bedroom - Yes ,Vo
Attached Narrative . Renovating unfinished basement Yes \I No
Plans Attached Roll - Sheet
* itK e ou e a firm cfditr WAissti q srr a dmqiefieytie>fd iowi q:
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
,,
4 ) T I, "� ��� , as Owner of the subject
property V Re. hereby authorize q 1 I ii c 1 k-
act on my b half, in all matters relative to work authorized by this building permit application.
1
�
Z ///
Signature of Owner � (J1 . Date
I, T' 1 10.1 � e ( C&._. , 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 belief.
Signed �uunder the pains a? of perjury.
r"1 \A-'‘ e _ 1 &
Print Name
.
Air ../ ) > 7
Signature .f • ner /Agent Date
i
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 1 __ {
Frontage ' ' < _. µ ____
Setbacks Front ) j
Side L: ___, R :L_...__- L':: _ R:l ___, , _,
Rear
Building Height f
L__: I
Bldg. Square Footage f j 1 % - 1 [
__ _.
Open Space Footage %
(Lot area minus bldg & paved _ a4 , . � S
parking)
# of Parking Spaces , ---- - — - --
Fill: ,l 1 _e
(volume & Location) — ,, _ -----
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO S DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON T KNOW YES 0
_
IF YES: enter Book Page t and /or Document #
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 Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Qrehere any proposed changes o or as 'Mons o signs mfende'd for the property ? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, gradin excavation, 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.
•
City of Northampton " x
Building Department
212 Main Street 4 g p - 2 � : 4
Room 100
Northampton, MA 01060
phone 413 - 587 -1240 Fax 413 - 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVAZE.OK.DEMOLUSH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION 1 , FED 1 6 2010
1.1 Pro ert Addre :
This section to be completed by office
2 Map Lot Unit
V
Zone Overlay District
EIm St District CB District
SECTION 2 • PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Pri t) Current Mailing Address: 0,
A
� f?-4.-752 f
Telephone
Signature
2.2 Authorized A ent:
KlIIN\ 3fI Lac
Name (Print) Current Mailing Address:
4 , � 3W(%
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 77 C' (a) Building 'Permit Fee
2. Electrical «' (b) Estimated Total Cost of
�� e Construction from (6)
3. Plumbing (xi Building Permit Fee
S ()
•
4. Mechanical (HVAC)
5. Fire Protection
6. Total (1 +2 +3 +4 +5) / ./z "= Check Number 279LQ
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /inspector of Buildings Date
File # BP- 2010 -0738
APPLICANT /CONTACT PERSON KIM RESCIA
ADDRESS /PHONE 311 Locust St FLORENCE (413) 584 -5816
PROPERTY LOCATION 63 REVELL AVE
MAP 38D PARCEL 063 001 ZONE SC(67)/URB(33)/
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: T1 FLR,REPLACE SHOWER FIXTURES & NEW VENT FAN
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 022464
3 sets of Plans / Plot Plan
THE FOLLOWING 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
. 2/ 2 J C
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.
63 REVELL AVE BP- 2010 -0738
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38D - 063 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 -0738
Project # JS- 2010- 001094
Est. Cost: $15120.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KIM RESCIA 022464
Lot Size(sq. ft.): 65340.00 Owner: PRIOR SCOTT W & NANETTE V
Zoning: SC(67)/URB(33)/ Applicant: KIM RESCIA
AT: 63 REVELL AVE
Applicant Address: Phone: Insurance:
311 Locust St (413) 584 -5816
FLORENCEMA01062 ISSUED ON :2/22/2010 0:00:00
TO PERFORM THE FOLLOWING WORK :TILE BATHROOM FLR,REPLACE SHOWER
FIXTURES & NEW VENT FAN
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
1 Footings:
Rough;: Rough :3 J` , 2 "GG / j House # Foundation:
Driveway Final:
Final: Li. o � 4, , Final: p p �1`
l RoughFrame:0t< 3\ I5 -
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: Ord 1 44 24 ( O L ott (S
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy 6 1-)%76,011 , - .; - , N 4 nature:
FeeType: Date Paid: Amount:
Building 2/22/2010 0:00:00 $90.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo