29-378 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 owir 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
iermits 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
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.
Date
Address of work
location
.
. . , The Commonwealth of Massachusetts
Department of Industrial Accidents
= �._ � Office of Investigations .
a= �1_
600 Washington Street
1= # Boston, MA 02111
"� www.mass.gov /dia
• -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers
Applicant Information Please Print LegibIv,
Name ( Business /Organization/Individual):. D C 6 n tts,1^ -. 6 k 1 J,.....
Address: y 9 go e�.-6 )11 l i Ra .
City/State/Zip: 1i,))) )14m, l 7111 0 l V 6 /6 Phone. #: t i/ ? 2_.9 4. 3 Z - 0
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
y have hired the sub- contractors 6 ❑New construction
employees (full and/or part-time).*
2_1g I am a sole proprietor or partner- t have on- the:attached sheet.. 7. 0 Remodeling
These sub-contractors ave.
ship and have no eloyees .8. Deraolit;on
working for me is any capacity. employees and lave workers'.
' _. comp. �sirranr.1 _ 9 Building addition
[No workers comp: insurance 10 repairs required:] 5. 0 We are a corporation and its 0 � Electrical
or additions
3.0 I am a homeowner doing all work officers havetTercised their . 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12:0. Roof repairs
insurance required.] t ' c. 152, §1(4), and we have no
employees: [No workers' 13.i Other �j i , ri (Z f p e, t
comp. insurance required.]. •
Any applicant That checks box #1 must also fill out the section below showing their worloas' compensation policy information:
t Homeowners who submit this affidavit.indicaimg 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 sheet showing the naive of the sub = contractors and state whether or not those 'unities have
employees. If the sub-contractors have employees, they must provide their workers' camp. policy number.
1 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-ins. Lic. #: Expiation 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 ofMO c 152 can lead to the iiiiposition'of criaumal 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 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 _
Tnvestimations of the DIA for insurance` coverage verification:- " — ==
I do b here • cn under the and penalties o .
-- __ —. -- �' _ e fy P P .fp�7�':tJsafthe irtformauon�rrovtded�bnv�u _true_asrirorrect - -. _ - -
i • .. ture: i . , - ... a 'i / o 1/ _ ,
Phone #: L i / 3 Z1 6 )111 . .2-b - . .
. ff y - mp ... by
Official use only. Do not write in this area, to be co 7plpd b or town bffe %a/
City or Town: Permit/License #
Issuing Authority (circle one):
.'1. Board of Health 2. Building Department 3. City/Town CIerk .4. Electricaljnspector 5. PIumbing Inspector
6.Other
Contact Person: Phone #:
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Q 1wW1 C 1 t S 1h o,e r 7 6 ) 3
V License Number
Address Expira ion D
W i `V aV s \ '3 4� N t. Ot o
Signature Telephone
• 1 3 296 g32o
. I_ P _; Not Applicable ❑
c. Q� s��,., a �1A y, /o yq
Company Name Registration Number
c t Ro sa 1.1, a -7 (V / �
Address 1 / (' 7 Ex irati n Date
wt�licrm, h , M� Mil ®1 04 Telephone 1 - 113 Z- 7Lo
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 I511 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)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding psi] Other [0]
Brief Description of Proposed n 1
Work: K pp 14 �� Zco 0 S71 ty sl d v+� .
Alteration of existing bedroom Yes ")4 No Adding new bedroom Yes ?° No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
g [f a t,fi :s alll a kitdlf1 6T ift a s a. c r aae t i d 6 i t'f :
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
1 I f t I f �S' J� , as Owner of the subject
property
hereby authorize -- De n'►■ s <
to act on my behalf, in all matters relative to work authorized by this building permit application.
SignSture[of 04 > Date
0 )1 rns Pitk/ril0K , 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 an penalties of perjury.
e>n v∎I c iff I r d ✓
caw
Print me e,
c c:///
Signature of Owner /Agent Date
t r .
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incompl to Information
Existing Proposed Required b Zoning {,
,
This column t be filled id 9 : t r a
Building Dep• ent y
i
Lot Size } i
R
Frontage ' 1 E
Setbacks Front 1 1
Side L: --- i R:�� L:£ R:= € s i
Rear `
Building Height r • ? ?
Bldg. Square Footage % 1 c"___I
Open Space Footage %
(Lot area minus bldg & paved [, . , I _ . I � .'
parking)
# of Parking Spaces 1
Fill: i �4.,,.,.rs.. ..,�....�...,�W.._._d_.. .......�..,.._..,..,�.�,A..��. .�.... .�..,...m.�� ..�u..� .,�
(volume & Location) 1 d 1
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:a
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book g Page ? and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q 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: ,
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: r
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
4
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.
°'1 I
City of Northampton 4
RECEIVED Building Department s .aq ` , ,
212 Main Street t = gt , =
MAY 1 U 20I1 Room 100
N rthampton, MA 01060 � �. � '44 �
o f BUILDING IN 41 587 -1240 Fax 413- 587 -1272 a >
NORTHAMPT MAO,''
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
Map Lot Unit
rive
ei A 17
�lJl.1 �J
s Zone Overlay - District
F ."}, 3 reti.ce --y'r)a.
Ekn St ;District,.: CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record::
1 Pr LA z- y to S' \C: k 6) e \or A t 2 Di-1\A_ Name (P� s Cu Mailing Address: in
T elephone
Signature - 4 1/3 S Li (--, 7 9 9
2.2 Authorized Agent: 0 )•o9 ,
v,>-„- s Q+ ev, 19 e= 1.1,It R Wlll►t,r 3bj MA
Na P rint) Current Mailing Address:
9 ( -Oitit---, Z-I /3 29` 43Z_O
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 1944C), p q (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection �
6. Total = (1 + 2 +3+4 + 5) 1 9 14 0. Check Number Y S
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector 0f Buildings Date
6 BROOKWOOD DR BP-2011-0930
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 378 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- 2011 -0930
Project # JS- 2011- 001513
Est. Cost: $1940.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DENNIS C PITTSINGER 007513
Lot Size(sq. ft.): 14897.52 Owner: PRUZ7YNSKI RITA
Zoning: URA(100) / /WSP Applicant: DENNIS C PITTSINGER
AT: 6 BROOKWOOD DR
Applicant Address: Phone: Insurance:
49 BOFAT HILL RD (413) 296 -4320
WILLIAMSBURGMA01096 ISSUED ON:5/12/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:1NSTALL 200 SQ 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 5/12/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner