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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
6 - 0i05k 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 014 ` 1 l 0
Address of work
location
re dt Ce- /1-1 4 - 1
7
V
. The Commonwealth of Massachusetts
Department of Industrial Accidents •
_W to i Office of Investigations •
t _ ��= 600 Washington Street
a� rr
L� --
Boston, MA 02111
www.mass gov /dia .
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information -'�' ) Please Print Legibly
Name ( Business /Organiaation/Indivi 1mi1): 64) n 11 'C. Iy:�. ,-t , (c - ( ` > g 1 { ,
Address:, / evt_ 0 k'. .
City /State/Zip: rIC i c'j L /I 0 /0& Wi -- t��
Are you an employer? Check the appropriate box:
4 I am a general contractor and I Type of project (required): /
.
1. ❑ I am a employer with have hired the sub- contractors 6. ❑ New construction.
employees (full and/or part-time).*
listed on the attached sheet. 7. 0 Remodeling
2_ ❑ I am a sole proprietor or partner-
ship and have no e These sub - contractors have . 8. Q Demolition
• working for me m any capacity 9 employees and workers' -
T Building addition
[ `o workers' comp: insurance COIIIp.�SJn anrP _ .. "-
required:] 5. 0 We are a corporation and its 10 Electrical repairs or additions
I am a homeowner doing all work officers havexercised their . 11 ❑ Plumbing repairs or additions •
myself [No workers' comp. right of exemption per MGL 12: o Roof a irs
c: 152, 1 4 and we have no
insurance reced ] t § () / ext
employees. [No workers' 1340-Other V i c - 41
comp. inaitrant -e wed,]
*Any appli cant -that checks box #1 must also fin out the section below showing theirworkers' compensation policy information:
t Homeowners who submit this affidait: indicating they are doing an 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 name of the sub = contractors and state whether or not those entities have -
employees. If the sub - contractors bave employees, they must provide their workers' comp- policy number.
I am an employer that is providing workers' compensation insurance for my eiployees. Below is the policy and job site
information. •
Insurance Company Name:
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/Stain/Zip: -
Attach a copy of the workers' compensation policy declaration page•(showing the policy number andexpiration date).
Failure to secure coverage:as required tinder .Secttoif25A 'ofMGL c: 152 can lead the ei nposition`of criminal penalties of a
fine up to 51500.00 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
Tiff estiaations of the DIA for insurance coveraae verification "
_ I do hereby _ fy un • the pains dp r; . ` , e ; ` , forma#wn provided_above issrue_and corrpet
/ ,that the in / / /�,
E l — / ; i/ D
Signature: by ` / t Date: r
Phone #:
L / / 3. 5 , 1. --- 94/0 3_ . .
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town: # _
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 )i
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9 to tlst M4om 4ftiliavettienita'iilir:ic fi ZE'Z _ .F , t Not Applicable X
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.I_. c. 152, § 25C.(fi))
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 ❑
1,U4:511:01niz *tier
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 co pli. , e with the State Building Code, City of
Northampton Ordinances, S � and L e Zoning L s and S e • M ach� tts•General Laws Annotated.
Homeowner Signature ' " ` , • - a 1 ,,
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) -
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. r4 Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [0]
Brief Description of Proposed f ' , i 1 , 0.0_ X i n - + / 4-
Work: r 1 , /��
Alteration of existing bedroom Yes k No Adding new bedroom Yes >_ Noy/
Attached Narrative Renovating unfinished basement Yes A No
Plans Attached Roll - Sheet
6a .:ttiai: oifs .. to i a> iilii iii .tiaa na t ita °# ' of Wiii:
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, ( , i C1 l��L 6o 1 � C: 1Z i
"' , as Owner of the subject
property / r / 'r
hereby authorize tit- r ` ` �� L �� S �r (
to a n my Vrlf, in all tters la ive worA aythorized by this building permit application.
Signature of Owner Date
1 1. ` r . 444..._. ; 60 0 4 ' '" ] , 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 u / nderr the pains and penalties of perjury.
Print N
— "0 ' , i el, ,, Iit: —.Ai ..... i'.1 0 —/ c; — 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
i id t c:4- 3 4 0 This column to be filled in by
f d I w. 10 , Building Department
Lot Size +y
Frontage ' /
Setbacks Front 1 1 f l' f / �
Side L 1 R:= ? L:;, R:��� y
Rear 1 , i Gm 4
Building Height DU w___.
Bldg. Square Footage [ I , 1 % ,, 1 1 i 1
Open Space Footage %
(Lot area minus bldg &paved _, 1 _...a.. ....i j�� 1 i
parking)
i
# of Parking Spaces i
Fill: I .,-W . — - — ' —
(volume & Location) L : 's , .
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO ® 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 YES 0
IF YES: enter Book 1 P ag e 1 and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ® 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
_ i
IF YES, describe size, type and location: 4
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO i
IF YES, describe size, type and location:
i
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 •
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
Building Department
21,2 Main Street - a
C3 / " Room 100
Northampton, MA 01060
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:
r t 7 (70 Map Lot Unit
Zone Overlay istract
r /Ur C'i1G� ./
-' 7 / y
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name rant) Current Mailing Address:
c�
Signature Telephone 9/3 5
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 f 0(0i a co (a) Building Permit Fee
2. Electrical _ (b) Estimated Total Cost of
Construction from (6)
3. Plumbing kr Building Permit Fee
4. Mechanical (HVAC) f
5. Fire Protection �l^
5 Check Number
6. Total = (1 + 2 + 3 + 4 + 5) >C® fA �
r This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
CHE n 64/2(46,6 T8p-c. ( s
File # BP- 2010 -0912
APPLICANT /CONTACT PERSON GOLASKI KATHLEEN L & WILLIAM J
ADDRESS/PHONE 68 GOLDEN DR FLORENCE (413) 585 -9403 Q
PROPERTY LOCATION 68 GOLDEN DR
MAP 29 PARCEL 429 001 ZONE URA(100) / /WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out f v �+
Fee Paid / / id(
Typeof Construction: CONSTRUCT 10 X 12 SHED
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
INFORMATION PRESENTED:
( Xpproved 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
9 c1, 10
Signature of Building Of 71,—/C
al 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-2010-0912
GIS #: COMMONWEALTH OF MASSACHUSETTS
'' CITY OF NORTHAMPTON
tot:' -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP-2010-0912
Project # JS- 2010- 001349
Est. Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 11412.72 Owner: GOLASKI KATHLEEN L & WILLIAM J
Zoning: URA(100) //WSP Applicant: GOLASKI KATHLEEN L & WILLIAM J
AT: 68 GOLDEN DR
Applicant Address: Phone: Insurance:
68 GOLDEN DR (413) 585 -9403 0
FLORENCEMA01062 ISSUED ON:4/26/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 10 X 12 SHED
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 4/26/2010 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo