24C-057 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
- • • - • • i 'ro ess.xequires 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
------ - - --pe m t-- in- canjunction,-to 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
.
E.
The Commonwealth ofMassachusetts
Department of Industrial Accidents
P =, = gl Office of Investigations
•
k= " h 600 Washington Street
_
Boston, MA 02111
www.massgovi'dta
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): 1 -I t ►M t\ S P S k A Q FE iv-
Address: 1S2 (, c N W 11 R C)
City /State/Zip: .G CFtt-I{, V3/ rk D i 3 f Phone. #: 413 ' (1 ' 3c q-7
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. 9 New construction
employees (full and/or part- time).* have hired the sub - contractors
2. I am a sole proprietor or partner- }fisted on the attached sheet. 7. Remode }1ng
ship "and have no. _.^vlo gees These sub - contractors have. 8. ❑ Demolition
for me in any capacity. employees and have workers'
working
Y P ty. 9. Q Braiding addition
co snranre...
[No workers comp. insurance �' � 10 Electrical repairs or additions
required] 5. 0 We are a corporation and its
3. Q am a iorneewner deiag all work officer_ have ‘xercie_d heir L1:-- PIumbiugrepairs or additions
myself. [No workers' comp. right of exemption per MGL 12.9 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 .mist also fl 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 sleet 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.
Iam 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 $1500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fire
of up to $ 250.00 a day against the violator: Ile advised that a copy of this statement may be forwarded to the Office of
Investications of the IIA for insurance coverage verification.
.
I do herebycerti under the pains and penalties of perjury that the information. provided above_ istruenruLcorr-ect_.__ _
Signature: ''1A/v` I '�' - Date: r� 4 ' 1 t;
Phone #: 11 '' P e 5 3 0'1-1 ..
— Official u s e o i l y . D o n o t W T g t e in dins IIreu, — to be completed by city or town OfficiaL
City or Town: Permit/License #—
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other r
Contact Person: Phone #:
r '
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. y� Not Applicable ❑
Name of License Holder : I i f S It E. P ,r 1` 5 i f 0 ( 3
1P)2, c.o 1 l A v R_ Lioenso- Numbor
, DF - E�¢ F L , MA OR 7, 19-03/9,0i l
Add ess Expiration e
Signature Telephone
9. Registered Home: ImprovementContracfor „ ';. ... Not Applicable ❑
S 19. siorac ( Company Name Registration Number
C na y 5 /i2/2.ct1
Address 1 5 . _ c c N w k y '� // "1 Expiration Date
S D E f 1J I t i. tJ I � (' I� ); Telephone 413 ' ( c - 3O f 1
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 ❑
IL O he € er motion
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
®o ampton 'Ors tnances, e a an .. _ ,, o - tts General -Laws- Annotated.
Homeowner Signature
� � R
f
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacemenb endows Alteration(s) Roofing ❑
Or Doors L4
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [El Siding [D] Other [D]
Brief Descripti of ro s Pkt \i I PC 14t.-v-4 1(�� L HEW CAS T S ] J ° 5 1
Work: �o� l 1, I ) Vl 111, D 1! w c z ( '- C awed V1 - its s 'i vvv. )
Alteration of existing bedroom Yes A No Adding new bedroom Yes 1' No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a, i Nevu'fifititlse arsr :oryadcli#lon tis exist ng io asl lct; coinplete`tt e °fa�towin t\
f ki
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, V\AA R./ O V 1 MC gl , as Owner of the subject
property
hereby authorize 7 tor, 'Sy. 1 GUVkiatil"1
to > on my behalf, all afters r tive t rk ai}thonzed by this bui ding permit applicatio
A• 311610
Signature of a Date
lit As S H Vc.pc J - , 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 under the pains and penalties of perjury.
fi ►� e, l"1r1 � Si-iAg -'E Jrz
Print Name
3/x1/ 10
Signature of 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 i s
LotSize _...__m,. .._ .. __.. "_ _ __,,__ "" .__._ „_ .._.__...., _ "...
C)
Frontage (
Setbacks Front tj
Side
Rear
Building Height
� U
Bldg. Square Footage % Z
V ...
Open Space Footage
(Lot area minus bldg & paved
pat king)
# of Parking Spaces
Fill:
(volume & Location) �.."
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Pager and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW $ 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: — dre there any proposei hanges to or a itions o suns intended for t property ? YES 0 NO 10
IF YES, describe size, type and location:
E. Will the construction activity disturb {clearing, grading, xcavation, 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. NJ/ /\
A '
1
City of Northampton S isifRermtt� s�
Building Department Cu fp33 ejrt'errr�t
212 Main Street
Room 100 elia a ��
Northaai '>}laton,MA_- 01080
phone 413-587-1240 Fax 413- 587 -1272 Piit1 I
bm Y♦ cQ a s 4- a
e p1.w rsG 36 .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:
AVE � \ Map Lot Unit
v 0 (L' \ IN\ Vroti j N - ( t 0 (q) Zone Overlay District
1
Elm St. CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
IiiA tS — — ?3 (4)Q t P Ndi2-D'Ittyttt�'N d�-
Name rint) / • Current Mailing Address: i 06'0
1 �`�-� / �Q
S ignature Telephone / / I Lf 1 3 _✓ ZS "'�' ^ 7 -� J
2.2 Authorized Agent: I C 2 N I'/
Ihemtic SW(\ypc, OBA Ti LtAvre,n41y 5.O €E IL IE(O, Mf - 013 73
Nam Print) Current Mailing Address:
C WX
413 ! d () - 201 1
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building / (n� (a)'Buiiding Permit Fee
2. Electrical I 1 U (b) Estimated Total Cost of
` Construction from (6)
3. Plumbing _ q 9 0 d� Building Permit Fee
4. Mechanical (HVAC) t�
5. Fire Protection
6. Total= (1 +2 +3 +4 +5)
aniliste Check Number /- �gb
This Section For Offi -Use Only
Date
Building Permit Number: Issued:
•
Signature:
Building Commissioner /Inspector of Date
File # BP- 2010 -0842
APPLICANT /CONTACT PERSON THOMAS P SHARPE JR
ADDRESS/PHONE 152 CONWAY RD SOUTH DEERFIELD (413) 665 -3047
PROPERTY LOCATION 73 WOODLAWN AVE
MAP 24C PARCEL 057 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out g/Q �jl
Fee Paid r
Typeof Construction: INSTALL KITCHEN CABINETS & CHANGE 1 WINDOW
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 054083
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION 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
Signature of Building 0 ficial Date 3/306
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.
A
,S1 �1 ( �� � /
73 WOODLAWN AVE BP- 2010 -0842
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C - 057 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 -0842
Project # JS -2010- 001252
Est. Cost: $25800.00
Fee: $154.80 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THOMAS P SHARPE JR 054083
Lot Size(sq. ft.): 11456.28 Owner: MORRIS ALVIN F & MARY DUFFY MO
Zoning: URA(100)/ Applicant: THOMAS P SHARPE JR
AT: 73 V VOODLA N AVE
Applicant Address: Phone: Insurance:
152 CONWAY RD (413) 665 -3047
SOUTH DEERFIELDMA01373ISSUED ON :3/30/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK: INSTALL KITCHEN CABINETS & CHANGE 1
WINDOW
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
/ Footings:
Rough: Rough: 7�3//o House # Foundation:
Lek:if / - ou$I) Driveway Final:
Final: 4t) Final: cOgi
Rough Frame: J( 1 14 l ( Litt t (
Gas: Fire Department Fireplace /Chimney:
Rough: E 1: Insulation: L " � 1< ,,,4c
Z jmoke: Final: (0 k� J l J
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
�� Certificate of Occupancy l i
i'Y Signature: � 4
FeeType: Date Paid: Amount:
Building 3/30/2010 0:00:00 $154.80
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo