31A-018 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 b e aware that
by doing so you become responsible for compliance with state building codes and
reg 1ations. inch ction _p_ro_cess_r.equires 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
secu - re 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
— — - - - -- – permits- in-conjunction_to_the_buildin g_Termit ued,_ 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.
Address of work
location
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
_ 600 Washington Street
r Boston, 111A 02111
lor www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
A
A. .licant Information Please Print Legibly
Name ( Business /Organization/Individual): , r " 't,ec: -P ,;, sal €y
Address: i-3 t 4,10 n-s , 0/03 7
City /State /Zip: /1 er .d i, l (e. 4 Phone.: 4t 3 .- 2x, r ; ?dam /K-
Are you an employer? Check the appropriate box: Type of project (required): /
1. D I am a employer with 4. 0 I am a general contractor and I 6. 0 New construction
employees (full and/or part-time).* have hired the sub - contractors
2. p I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have. no P^'Ployees These sub - contractors have. 8. 0 Demolition
working for me in any capacity. employees and have workers'
9 0 addition on
[No workers' come. insurance c n3suz - -
required] ed 5. 0 We are a corporation and its 10.0 Electrical repairs or additions I
3. -0 I am. a homeo-wner- doing- all -work - 9 exshave e xercised their - -- .0 P1 bigg 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.[EI Other ee-'p /{-€ .�
comp. insurance required.).
*Any applicant that checks box #1 must also fin out the section below showing their workers' compensation policy infomration. .
t Homeowners who submit this affidavit : indicating they are doing alt work and then hire outside contractors must submit a new affidavit indicating such=
:Contractors that check this box must arttrhed an additional sheet showing the narne of the sub = contractors and state whether or 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 worker' compensation insurance for my employees. Below is the policy and 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 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 ofa STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. to 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 ce q under the pains and penalties of perjury that the infonmation.rovrded abov issrue.andcorrect___ _ •
Si . , tore. �, u v- s ate. t . _
Phone #: 41 ", / c,
Ojj`icfal use only. Do not write in this area, to be comp led by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
I Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical I, , ector 5. Plumbing Ins. ector _
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Ap ❑
Name of License Holder : r cdG Q C..Lce tt_GQ 4 � 3
License Number
Address c io3 y Expiration Date
/
�— 4/3 -z6,
.nature Telephone
9::Registered% Home °Irai - Gontractar ,._ ., �� - . Not Applicable ❑
-_
Company Name Registration Number
5 ' `p=„5 — ZO /U
Address Expiration Date
d e
rt... � 1 d � Dl 0. 39
T on
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 ❑ No ❑
1 . 31 me' e kIli'p`iT011
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 1083.5.1.
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
orf amp on ® t• i finances; a e an. • , , _._ , .• • � ;_ . ; ::- , - ,, , o eneral-La - -ws- Annotated.
Homeowner Signature
t
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) J Roofing E]
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [O] Other [51]
Brief Description of Proposed IE'¢ p (QC C 'Ack S f Q f S To POIt e.4 EN 7,Lq, t 6 C
Work:
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll - Sheet
6a.: 1f,.New houseandor. addition.to existirighouslnO„ compete the .follo vinq:
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
I, C,..vh S+ - Chic< 1- 'PS it 2 , as Owner of the subject
property / ,_, _-
hereby aut- • riz= E rV -ALA pct u s CIA Q.''
to act o y • -half, in - a e to work authorized by this building permit application.
.�. �4 ,7 1 -/ 7°0
Si - . ','-er Date
n rc,tee (ata [ G , 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 and penalties of perjury.
2 r4c e a,Se -ti
Print N
Signature of Owner /Ag nt Date
• a
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
Lot Size _ .,
Frontage
Setbacks Front
Side L.____.. R...__. L: ...... R. _
Rear
Building Height
Bldg. Square Footage %
Open Space Footage
(Lot area minus bldg & paved m_
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book a Page' and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 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. Do any signs exist on the property? YES 0 NO e
IF YES, describe size, type and location: __'
D. - there ao ` rose cFian es to or a pions o. si intended intendd Tor the YES 0 NO
YP Pod � - g '; f property �
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.
4
DPsattitt - b iti tll z
City of Northampton
Building Department Cu �pneway Ieritt
1 7 z% 212 Main Street seuv t$emieAvtafri� r z
Room 100
NorthOripton, MA 01060 m e ®�#tuch3r I Plan � a
phone 413 -587 -1240 Fax 413 - 587 -1272 Pjt .S at e
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
S vx. S +v Map Lot Unit
MOT-441. 4 p M Zone Overlay District
tvt. blm'St-District CB District
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of R- o d:
C o , e 14s e 4-- . 5C1 el '
Name (Print, iA Current Mailing Address:
4i3— 5d - o szs
A_� � Telephone
Signature 11°F
2.2 Authorized Agent: A ®/O`3 9
i U c'e /C1�tsG�i '$ Y ED E Ihc c> u # / !e M
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 If> 750 a cf (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Budding Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 +2 +3 +4 +5) Check Number •0/9
This Section For Officia[ Use Only
Date
Building Permit Number: Issued:
Signature: _
Building Commissionerilnspector of Buildings Date
File # BP- 2010 -0303
APPLICANT /CONTACT PERSON BRUCE TAUSCHER
ADDRESS /PHONE 54 ADAMS RD HAYDENVILLE (413) 268 -3814
PROPERTY LOCATION 4 SANDERSON AVE
MAP 31A PARCEL 018 001 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 W7
Tvpeof Construction: REPLACE BACK STEPS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 087399
3 sets of Plans / Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN ATION PRESENTED:
A pproved 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
/
Demo ' ion Delay
-‘-} . „. 7V e---' 4L------- /Z
7„ 2/c7
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.