22D-111 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
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
7.
. ..
,\ • The Commonwealth of Massachusetts
Department of IndustHal Acidents
Office of Investigations •
• 600 Washington Street
e, -.,.1:=. ••v• Boston, MA 02111
• ' ' www.mass.gov/dia .
...
Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly -:'-
,
Name pusineseorganizationadivicinno:
Address: 27 i,,91/-?(____- It i lei )
4 OIO?f.. n
City/State/Zip: /4".9 t /- j one.#: 113 - (a 7- ,P7
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 I • 0
, . employees (full and/or part-time)•* have hired the sub-c 6. New construCtion ontractors
listed on theattached sheet 7. fR Remodeling
2.,M I ant a sole proprietor or partner-
These sub-contractors have 8. 0 Deniolidon
• . ".. and have n .7oloyees
errAiloyees_and_h uil
ave workers' ._ ___
working for me in any capacity. 9: LI Bdmg addition
[No workers' comp. insurance
10.0 -Electrical repairs or additions ,._, reVirect-1 ' • 5. 0 We are a corporation and its
3. LJ I am a homeowner doing all work officers havexercised their . 11.o Plumbing repairs or a dffitions
•
myself [No workers' comp. right of exemption per MGL
12.0 Roof repairs . -
insurance require:1:j t • p. 152, §1(4), and we have no •
13.0 Other
employees. [No workers' •
comp. insurance reqnired.j. - •
*Any applicant -that checks box #.1 must also fill out the section below showing their workers compensation policy information:
t Homeownera who subtnit this affidaVit inclicating they are doing all work and then hire outside zontractors must submit anew affidavit indicating such. .
:Contractors that check this box must attached an additional sheet showing the nanie of the sulcontractors and state whethernrnotthose entities have •
employes. If the sub-coniraCtorshaVe employee, they must provide their woricers' comp. policy number. •
.
lain an employer that is providing workers' ci9mpensation insurance for my employees Below is the policy and job site
information. /
Insurance Company Nam l e:
/ . , • .
Policy # or Self-ins. Lic. #: Expiration Date:
. . .
Job Site Address: : City/Stafe/Zip:'
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required tinder SeetibiT25A 152 can lead to the imposition u'u'n1 Penalties of a
fine up to 51,500.00 and/or one-year imprisonment as well as civil penalties in the form pf a STOP WORK-OIZDER. 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
- EiV - eifiOlis Of the Dalai= insurance rAiii . ..... - - !: - :77 ---- . - 7 - 77. -- '__=-. - . --- .,,
_ I do hereb_y,certifi der the pains.and enalties „perjuiy that the informationprovididnbitv - °Tie&
,
Date /Z- ,.— ( ..,, /7 z'')
Sinnatre: , • - . / - : L..... J
Phone ii: -1 / 3 74 .- 7 9
Official use only. Do not write in this area, to be completed by city Or townelciaL
City or Town: •
Issuing Authority (circle one):
'• • Permit/License # • .1. Board of Health 2. Building Department 3. City/Town Clerk 4. EleetricalInspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : /rte J V7 Y - 33 - 210
License umber
�/�
Addre Expiration ate
1/3 9 l _ 9
Sig ure Telephone
` ifilaalittli:77t1SNZZEMZ Not Applicable ❑
//o Z3
Company Name Registration Number
Z vA7 2 ' s) /
Address Expirati Date
51 Telephon#J5 — 7
—
SECTION 1Q 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 ❑
tiZA
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 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
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 p Replacemen4indows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [1:7,1 Siding i t174j Other [0]
Brief Description of Proposed C7
Work: / 7Z' C" / /977/ l / M4 D eL///
Alteration of existing bedroom Yes ✓ _ No Adding new bedroom Yes 7No
Attached Narrative Renovating unfinished basement Yes / No
Plans Attached Roll - Sheet
Oa tilt _ h0 15 ' 4 -' 4 ; :: Illaaii aitl il i f<Ii. ; 41W * t a # iii nicti"' ric :
a. Use of building : One Family ∎/ Two Family Other
b. Number of rooms in each family unit:_ ;' Number of Bathrooms T
c. Is there a garage attached? - s�
d. Proposed Square footage of new construction. /1/// Dimensions -3 X..Z
e. Number of stories? ✓ j f. Method of heating? `l/ f 7 -1 ' Fireplaces or Woodstoves y /
_ Number of each
g. Energy Conservation Co mpliance. /�C Masscheck Energy Compliance form attached?
h. Type of construction l
i. Is construction within 100 ft. of wetlands? Yes L No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade ryZ /./
k. Will building conform to the Building and Zoning regulations? X., Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN ,
OWNERS AGENT OR CONTRACTOR APP ES FOR BUILDING PERMIT
/ - _
A I, A -G-c.- ' , as Owner of the subject
7` prop rrty ,
hereby authorize
to act on my behalf, in all matters re v to work authorized by this building permit ap lication.
Signature of Owner Date /
1, r Gl ec�!'/'� as Owner /Authorized
Agent reby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and pen (ties of perjury.
/ i _iF - /tom' /Ff/2
Print ame I
-. em u z,, -( ,h <G L -e-1-L ( /2 :/ /77 //4
Signature f Owner /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 I _ , I
Frontage 1 I
• i
Setbacks Front i = 1
Side L:G ? R: _ L:? I R:____.._'
Rear 7
L
Building Height 1 __J E 1
Bldg. Square Footage r I � rni % F-1 -
Open Space Footage %
(Lot area minus bldg & paved E,. _ i i 1 - 1 -
parking)
r;- i ? _ 1
# of Parking Spaces
Fill: _ .. ,... _ - .., , ._� . .. ..
- *.,F.r . N ..—,
(volume & Location) f i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO er 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 & 1 Page I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO `, r DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ,Date Issued: 1
C. Do any signs exist on the property? YES 0 NO i] A
IF YES, describe size, type and location: L
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location: i !
E. Will the construction activity disturb (clearing, grading, ex 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.
city of Northampton ®_ - .'t '
Building Department
212 Main Street
Room 100 s
t. Northampton, MA 01060 '.'; � �
' s' v m ` b ," r �: g. a 4 ,�
�. phone 413-587-1240 Fax 413 -587 -1272
. i gym_ u..
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
17 4"1/ 1 7E -.� 'Ma Lo t Unit
9� / /
/06Z ::Zone , Overla Distlemct
Elm St. District_ CB District
SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: 17 4v /s c //C.
&y 7, , i
/ /ei , /if/5 0/l56
Name (Print) Current Mailing Addre /3 .2n ..._/7,,,?./
./ , Ji 1 Lam"' Telephone .,./
Signature
2.2 Authorized Agent:
� i sm � LiG'! Y� ip
// /iiC 1. h' ce_47
Name (Pri 4 Current Mailing Address: 0/ ..z 777
,Z17,-(..d." /i /r/. .4 cip A)
Signatu Telephone
SECTION 3 - :ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 5 / o66 (a) Building 'Permit Fee
2. Electrical 7" 600 (b) Estimated Total Cost of
Construction from (6)
3. Plumbing 2 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5)4''4 � � S�0 Check Number , / 5 p�79`
This Section For Official Use Only
Date
Building Permit Number: Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0568
APPLICANT /CONTACT PERSON DENISE LUCIER
ADDRESS/PHONE 87 BEAVER LAKE RD WARE (413) 967 -9898
PROPERTY LOCATION 47 AVIS CIR
MAP 22D PARCEL 111 001 ZONE URA(100) / /WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out / ��� oa7y
Fee Paid
Typeof Construction: REMODEL KITCHEN & BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 55210
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
2.12,; /v
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.
c ' Plq,Ai F (\
47 AVIS BP-2011-0568
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 22D -1ti 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- 2011 -0568
Project # JS- 2011- 000938
Est. Cost: $46500.00
Fee: $279.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DENISE LUCIER 55210
Lot Size(sq. ft.): 19253.52 Owner: KEEFE GARY W & ALLISON S
Zoning: URA(100) / /WSP Applicant: DENISE LUCIER
AT: 47 AVIS CIR
Applicant Address: Phone: Insurance:
87 BEAVER LAKE RD (413) 967 -9898
WAREMAO1082 ISSUED ON:12/28/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN & BATH
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 12/28/2010 0:00:00 $279.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner