24C-186 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 Anal buntline insuecliun. Ilie
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
l
I I, understand the above:
(Home owner , sident's signatu requesting exemption)
I will call to schedule all required bui mg inspections necessary for the building permit
issued to me.
Date (e 7 ( )
Address of work � < Cil �e 5 location ireef
A DID(00
0\inAILk Al .
l
7
. L\ The Commonwealth of Massachuset
=4=4— Department of Industrial Accidents •
P a ---z,--- f/
Office of Investigations
S
h
600 Washington Street
t ..y
Boston, Mel . 02111 •
www.mass.gov/dia
. ._..
•
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le2
Name (Busineseorganizationandivichao: -
• Address:
City/State/Zip: .. . Phone.#:
Are you an employer? Checkthe appropriatehoxi •
Type of project (required): /
1.0 I am a employer with 4. 0 I am a general contractor and I
6. Ei New construction
have hired the sub-contractors
employees (fall ancVor pi).*
listed on the attached sheet 7. 0 Remodeling
2. 0 I am a sole proprietor or partner--
ship andbave no e These sub-contractors have .8• 0 Demolition .
employees and have workers' • •
working for me in any capacity. 9. - 0 Build* aditi On
[No workers' comp. insurance • _ C0.11113.10SITMni t .
10.0 Electrical repairs or ackfrtions
required.] .- 5. 0 We are a corporation and its
3. I am a homeowner doing all work
71,
myself [No workers' comp. officers havexercise4 their . 11.0 Plumbing repairs or additions
rieit Of exemption per MGL r-7
12.0 icoor repairs . • '
insurance required] t ' c. 152, § 1(4), and we have no
110 a ..
employees. CNo woPkers'
comp - insurance required-1
*Any applicant -that checks box #1 nust also fill out the section beloW showing their workers' coropensation policy information. , .
t Homeowners who submit tins affidair iracatirti they are doing ail work and then hire outside contractors must submit anew afEdavit indicating such.
:Contract= that rhiv+ this box must attached m additional sheet showing the name of the sub-contractors and state whetheror not those entities have
employees. lithe sub-contractors have employees, they must provide their worlcers' comp. policy number. .
I azn an employer that is pi-oviding workers' compensation 'insurance for my einployees. Below Ls the policyand 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 udder Section 25A ofMGL c. 152 can lead to the iMPOsition of Crim.ini.1 iienaliies of a
fine up to S1,500.00 and/or one-year imprisonment, as well as civil penahies in the form of a STOP WORK-ORDER and a fine
of up to S250.00 a dar against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Etv of the DIA for hisMince Cove irerification. ...„
I do hereby_ce )51 un pains and penalties ofp that the info ., i nprovidednbov _and_corrert
• — (64'46 D aiX: TT- /n.. ,
1/Signatare:
Phone it: al ( 5c1-4 t ,55 -or cr_l cf6, .3,F ,R-kig 6
. - Official use only. Do not write 'in this area, to be completed by cfry O r tow nOfficiaL
City or Town:
Permit/License # _
Issuing Authority (circle one):
.- '
.1. 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 Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
Ekc1iS #11t1111d;nigtQtetl�Ntli�t;" < f 2 a Applicable �' :. �" Not otA livable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.O.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.
Wined Affidavit Attached Yes U 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, Sta " d Loc. .nmg ws and State o t Massachusetts Gene Laws Annotated.
r Homeowner Signature
J 1
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 [0] Decks [p Siding [O] Other [0]
/Brief Description of Proposed /� r l _ � 1-v C /� PAIWI Work: �O
fyC��v C-GV1 ( l� �l ltAq 1 j/vti �! �C
Alteration of existing bedroom Yes 1 ,/ , '" - No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
tia ` €!�Ica�Ii�l wxn _c pt�oe theirlr:
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 la - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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
U (A V \ 4 — r �.s G ! L- , as Owner /Authorized
Agent hereby declare that the statements and information on the tb!egoing application are true and accurate, to the best of my knowledge
and belief.
Signed n ertvpains and Penalties perjury. , C n
Cal Prjnt Nam (A)1/1//' #111 f
l gate
Signature of Owner /Age '
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
g
' Lot Size 1 i �. t
1
Frontage 1
1 m ! I 1
Setbacks Front I 1 1 i
Side L:�___? R:J L:I — _._...._ R: i I
Rear t h
Building Height 1 i i i t
Bldg. Square Footage 1 • 1 % 1 __._
i
Open Space Footage % I
(Lot area minus bldg & paved 1 ? j
parking)
# of Parking Spaces 1 r — M
Fill: i m �_._«. V. ...�__.�..�__�...�..�.. €m ..�...
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:;
1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I I Page 1 and /or Document # __
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ,Date Issued
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location: I
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: I
E. WiII 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 ® NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton _ Rf
Building Department
F .:T
212 Main Street
Room 100 q,
r‘ (> ) t orth MA 01060
vv A phone 413- 581240 Fax 413 - 587 -1272
,
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
C\-esu c14 J Map Lot Unit
'Zone, `L , Overlay District
tint St: Dtsti1ct CB - District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: get° Oi" • fa
1VU- V 1AC( 601Ct-elICI 2 7 Da fri c■ ft 6-
Name (Print) Current Mailing Address: ! 3 I
f� Telephone !
- - - -- Signature • ■
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION: COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building iJ (a) Buildi
,G ng Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing / 1 —_ 1 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) Check Number 0 d 5 5
This Section For Official Use Only
Date
Building Permit Number: "Issued:
Signature:
Building Commissionerfnspectorof Buildings
Date
File # BP- 2010 -1109
APPLICANT /CONTACT PERSON COHN MERYL & MARY BETH CASCHETTA
ADDRESS/PHONE 27 DANA ST NORTHAMPTON (413) 398 -8486 0
PROPERTY LOCATION 211 CRESCENT ST
MAP 24C PARCEL 186 001 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 p7 o W 5
Typeof Construction:_RENOVATE BATHROOM
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INATION 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
6 P/N
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 -1109
GIS #: COMMONWEALTH OF MASSACHUSETTS
Tip` Y 29 - 186 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 -1109
Project # JS- 2010- 001629
Est. Cost: $5500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 5924.16 Owner: COHN MERYL & MARY BETH CASCHETTA
Zoning: URB(100)/ Applicant: COHN MERYL & MARY BETH CASCHETTA
AT: 211 CRESCENT ST
Applicant Address: Phone: Insurance:
27 DANA ST (413) 398 -8486 0
N O RTHAM PTO N MA01060 ISSUED ON: 6/10/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: RENOVATE BATHROOM
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 6/10/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo