24C-119 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
_ It
. - .
•
The Commonwealth of Massachusetts
Department of Industrial Accidents •
t. =L.... ' Office of Investigations .
600 Washington Street
Boston, MA 02111
, • - ' www.mass crov/dia .
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/IndividlInD: ...r_ \- V v\ , , / k C L Irn t , ,g , T 0 & j In :, x \*
t \ 9 ,- v , i ..,, 7
Address:
' r ' 3 5 i
fr\ 4 (.2 1 C ) -1-
CitYl Stateaip: - F ("I \ I-. ,,,, 1,-, ( f ,-. Phone.#: 1 1 7 1 9 --- ■ A D- j
- ,
Are you an employer? Check the appropriate box: Type of project (required): l
•
1. 0 I am a employer with 4. 0 I am a general contractor and I
6. 0 New construction
have hired the sub-contractors
employees (full and/or part-time).*
listed on the attached sheet 7. p..ktemodelirig
2. I am a sole proprietor or partner-
These sub-contractors have
shin and have no iloyees 8. .ipeiziol.on
•
employees_and have workers' -
working for me in any capacity. 9. 'ID Building additi6n
-
_ _
[No workers' comp. insurance comp.ins-mmirte.f_
requ]red.] - 5. 9 We are a corporation and its 10.p Electrical repairs or additions
3. 0 I am a homeowner doing all work officers have4xercised their . 11.L71.Plunabing repairs or additions
myself [No workers' comp. right cif exemption per MGL
12.0 Roof repairs . •
insurance required.] t ' c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. ms-Lance required.] • •
*Any applicant that checks box #1 must aLso fill out the section below showing their workers' compensation policy information. • '
I Homeowners who submit this afrada;fit indicating they are doing all work and then hire outside contractors must submit anew 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-contractorshave employees, they must provide their workers comm policy number.
I 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-his. Lic. #: :Expiration Date: •
Job Site Address: City/State/Zip:*
Attach a copy of the workers' compensation policy declaration page (showing the policy numl:Her and expiration date).
. _
Failure to secure coverage . as required under Section 25A OfRIGL c. 152 Can lead t6 the ]inpOsitiOn of ctimita41 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 /TM'
of up to S250.00 a day against the violator. Be advised That a copy of this statement may be forwarded to the Office of
V iifthelDIA for niturance Coveraie Verification.
I do herebycertifr under the pains and penalties ofperjury that the information provitled:Ubove_isInse_and_corre._______ _
Signature: 4/ "\----- ,-• 9 Dair: \ \ 1 1 i v•
Phone #: Li k- - c11:)- 1'13 )--- -
Official use only. Do not write in this area, to be completed by city or town 'official
• • .
City or Town: '• Permit/License #
- _ ... .
Issuing Authority (circle one):
.1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical 5. Plumbing Inspector
6. Other , k- •
■
Contact Person: Phone #:
SECTION 8 CONSTRUCTION SERVICES t ,
8.1 Licensed Construction Supervisor: Not Applicable ❑
A Name of License Holder : Val u\ ' 1 c V., r t V U
License Number
_ M "
Address 6 t Expiration Date
i
'Signature Telephone
0.4RedisteWifkilii4iiiiiiiikrinifitittliiiiiibliliealailliaNZAEULL Not Applicable ❑
o 0 113 0 \i 1r _ y 1 Jar v r r I S } x
Company Name r e } Registration Number
S � � 3 t � �; k �, M I d 3 1
Address Expiration date
Telephone L t l
i I = t i — _
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 yk No ❑
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
+;. s ,
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [] Addition ❑ Replacement Windows Alteration(s) Roofing El
Or Doors rEl
Accessory Bldg. ❑ Demolition F New Signs [0] Decks [C] Siding [El] Other [0]
Brief Description of Proposed
Work: O r" o /n ofr t � 5 T n r + j, Ktr(yter'
Alteration of existing bedroom Yes )< No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes X' No
Plans Attached Roll - Sheet
sa��l�te�i�� ll�s�an+d=rc.��it�c[ii�rr,` �isfin�asihq cn�npiit� #h`_folt+�wrc�:
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
1 t rf I g tzt c` tJ , as Owner of the subject
property
hereby authorize t■J /r-C k r^A
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature o Owner Date
V 1A./ ' t . t , as Owner /Authorized
Agent hereby declare that the state ents 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.
/1 c ( � jn . i' LA
Print Name
Q . p It()
Signature of Owner /Agent Date 1
r
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomp Infori ation
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size '1 6 V c2 -.1 1 / 1 1
Frontage 1 ‘ e< 1 1 V ( 1
Setbacks Front _
Side L: ` R L:1 l R J
Rear L_1 Ai .
Building Height 1,771 ,r,R
Bldg. Square Footage 93 % ( l
Open Space Footage % _ i
(Lot area minus bldg &paved t� n�? ..�?
parking)
# of Parking Spaces — --- -~
i "
Fill: i ,z , 3
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:I
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 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued: ,
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO C
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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
. 1
. t"a m t
City of Northampton 3 f f �
Building Department r
212 Main Street
Room 100
c << Northampton, MA 01060 :L
phone 413 - 587 -1240 Fax 413 - 587 -1272
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: f r
r t H A vc
Map Lot Unit
NOc - Th4M ?NC r\-
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
CL EtC,2 (eri S frrti /vc, N R-riii ,J h4 01 v 6 0
Name (Print) Current Mailing Address:
6( "712 9406
--1.=.-2 - -_ __ Telephone
Signature
2.2 Authorized Agent: } f
Y w IA A L k 1 ,1 S r r ,. -, ` _1 A s ? �` "` .1 I`'
Name (Print) Current Mailing Address: 1 /M n. t / t 1
' r �'' 2 1- l 7 1 1 1 I `1 , - r
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
? , o ) ' Construction from (6)
3. Building Permit Fee
, r - r.
4. Mechanical (HVAC) C j f
5. Fire Protection _ y
6. Total= (1 +2 +3 +4 +5) )a L 'l 3 Check Number /.J O 7
i
This Section For Official Use Only
Date
Building Permit Number: ..,' Issued:
Ae
"
Signature:
Building Commissioner /Inspector of Buildings Date
8 FIFTH AVE BP- 2011 -0403
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C -119 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP- 2011 -0403
Project # JS- 2011- 000669
Est. Cost: $111.00
Fee: $111.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Irwin Achmad 100992
Lot Size(sq. ft.): 6969.60 Owner: COFFEY DONALD J & EDNA K & ROBERT H & DONALD P & KEVIN F &
THOMAS F
Zoning: URB(100)/ Applicant: Irwin Achmad
AT: 8 FIFTH AVE
Applicant Address: Phone: Insurance:
7 Spring Street
EASTHAMPTONMA01027 ISSUED ON:
TO PERFORM THE FOLLOWING WORK: Renovat Kit & Dining Area
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:
FeeTvpe: Date Paid: Amount:
Building $111.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck - Building Commissioner