29-151 •
•
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 ow 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 occunancv
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 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 nre.
Date
Address of work
location
r
The Commonwealth of Massachusetts
Department of Industrial Accidents.. 4
E• i� _ !t Office of Investigations
e n: MOM Ty 600 Washington Street w
t'I= Z Boston, MA 02111
�t www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information . Please Print Legibly
Name (Busineseorganizat onandividua1): 1 V red 6 -' ` _21 c--
• Address: i ce ' / 6 if , . . , _ . ) /37) - • t ne City /State/Zp: A r� , 1 c .#: ? ' 7
Are an employer? Check the appropriate e box: . . • Type of project (required):
'� 4. I am a general contractor and I ] ( i
1. I am a employer with --31---- g ti_ New co
— --
employees and/or parrttine�: * have hired the - sub -csub
— —
- --
2. I am a sole proprietor or partner- listed on the attached sheet. 7- ❑ Remodeling .
• shirTind have no a loyees These sub have .8. ❑ Demolition
working employees and have workers'
E f or me in any capacity. tY 9. 0 Building addition
[No workers' comp. insurance COIDP. insurance-I
re • 5. 0 We are a corporation and its 10.0
ed. Electrical repairs or additions
q� ]
3.0 I am a homeowner doing all work officers have e xercised their: 11.0 Plumbing repairs or additions
right of exemption per MGL
myself [No,workers comp.. 12.O. Roof repairs -
insurance requires.] t • .c. 152, §1(4), and we have no •
employees. [No workers' . 13.0 Other
comp. insurance requited. }.
`Any applicant That checks box #1 must also fill out the section below showing tbca worloers' 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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whetheror not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information. p > ,, 7
ta.
Insurance Company Name: A / i / 7 - 1.) f t 2 -if / ,L i•-) l b ` " .
Policy # or Self-ins. Lic. #: U o — 7s 'f' L t ! 1 c , J •
Job Site Address: JO l S �g 0 C ./t` �' ) /i� 0 2 C /Stn ''' 2 , 0 r ) c , Iv , — . ���s�.1
rty te/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 51,500.00 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. Be 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 pains and penalties of perjury that the information provided above is true and correct
• 1 .
'47 • j
- Si y, :to _ t _ � � .Date: _ - - —
.:
Phone #:
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,Inspector 5. Plumbing Inspector
6.Other Y
Contact Person: Phone #: I
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: L Not Applicabl2 ❑
Name of License Holder : .G= 4 v I L '°-' tx o
License Number
F /: iz oe 6 .0 4-effei-4/ c)ar ;
Address Expiration Date
A i rn TG sk..) 01,c C C . 7
Signature Telephone J -(1/67 0) —
Not Applicable ❑
Company Name Registration Number
P 7S1 10044 4,
Addre s Expiration Date
t
b i c ° , 1 , 4 y '01.) ` � Q/� Telephone �2� - 4 7 Q 6 -1 0
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT'! (M„ GL. c '152,:§ 25C(6 }
Workers Compensation Insurance affidavit ust be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildin permit.
Signed Affidavit Attached Yes 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
•
,
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
ti ,
New House 0 Addition ❑ Replacement Windows Alteration(s) El Roofing El
Or Doors 0
Accessory Bldg. El Demolition 1:1:1 New Signs [0] Decks [[J Siding d Other [lam]
Brief Description of Proposed r J
Work: --� T 11 i p f Sl o f l
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
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 constructibn
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
® j J jJ ✓ u / J ! / 4 61_ 1 , as Owner of the subject
property �� 11�� ..y r�
hereby authori Li� r0 & 1 d A O
to act o behalf, in all matters relative to work authorized by this building permit application.
t//
Signature of Owner Date
/"� , , i
I, �-- %e l ) ,` A L 1a c asAuthorized
Agent hereby declare that the statements and information on thi foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
ZF, W r L y e a
Print Name .„
,zi d/ L
Signature of OweFlAgent Datl
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information s ' - t
Existing Proposed Required by or[ing
This column to filled in 1 l a w jk .►
Building Depaent i�3�lii/I1��
Lot Size 1 1 1 v,. ..,„ w. a *
Frontage
Setbacks Front E= 1 1 1
Side L:= R:1 L:i R:1 1 1_1
Rear 1 1 1
Building Height = 1 1
Bldg. Square Footage 1 1 1 % 1
_Open_ Space Footage # -1° _
(Lot area minus bldg & paved b
1 L [ 1
parking)
# of Park C l _I
Parking Spaces .
Fill:
(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 Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
c
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
— 1
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
_RECEIVE
City of Northampton _ u
----- D
Building Department a ,' $ z Q ;�� ..4 ', 4�� 3
212 Main Street -i 1 .as 1 e ' � :
-4 21111 Room 100 PF i x. „�,[ -, c, � � ,
0 c -rte , g €
N )rthampton, MA 01060 a - - ;.., ! -. �, .
413 - 587 -1240 Fax 413 - 587 -1272 a f ;{ Eg � tl
:
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:
,V 7 SpLuGef D `s , � . . ` �,>
Y'' / 41t y : a,x 4Y I ii 4 is #0ct
d -
E C t CB D
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: t
N � Ft, >J �A . ) Q 7 s a le �.� c, e..' /h // /4 6
Name ,�"� Cu, • $ Ma Address: _ ,r 0 16 7
/ % *�._ / .. ,../'� Telephone L1
Signature d icy
2.2 Authorized Agent LP
Name t) Curre t Mailing Address:
_ . ) -C O 4 6-. .I )€ 01( a
Signature Telephone
SECTION 3 - 'ESTIMATED CONSTRU ONCOSTS!
Item Estimated Cost (Dollars) to be Offic Use Only
completed by permit applicant
1. Building it'E� 0 0 i (a). Budding Permit Fee
2. Electrical (b) estimated Total Cost of
Construction from (6)
3. Plumbing CBuliding Permit Fee
4. Mechanical (HVAC)
0,715 5. Fire Protection
ff
6. Total = (1 + 2 + 3 + 4 + 5) ,t 0 0 a` Check Number s .. *4
5.
This Section For Official Use Only
Date
Building Permit Number Issued,
Signature:
Building Commissioner/Inspector of ” Date
A .
107 SPRUCE HILL AVE ` BP- 2012 -0013
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 151 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit # BP- 2012 -0013
Project # JS- 2012- 000021
Est. Cost: $5200.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R SIDING 026846
Lot Size(sq. ft.): 66646.80 Owner: FUNGARLI DONNA
Zoning: URA(100) //WSP Applicant: B & R SIDING
AT: 107 SPRUCE HILL AVE
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586 -4167 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON: 7/6/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL VINYL SIDING
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 7/6/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner