31A-295 (4) 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
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
Date
Address of work
location
-,,
` — •
..... .- ., ,
. The Commonwealth opfassachusetts
--7--fr--.4-- Department of Industfial Accidents -
Alt __E:-...r•-z-- fi,
Office of Investigations .
600 Washington Street
1,Bif
a
Boston, MA 02111
-_
- , www.mass.gov/dia
• _.,
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electhcian.s/Plumbers
Applicant Information - Please Print Legiblv
Name misinessiOrgamzationfIndividuaI) 2 r . C..,
- Address: 3 z- .."'S F ,A V---)....
City/State/Zip: I Tk\f\ct.Vv--1)+c Phone.#: ?i3 2-ig z1
Are you an employer? Check the appropriate box: • Type of project (required): 17
• 1. 0 I am a employer with 4. 0 I am a general contractor and I • 6. E] New construction
employees (full and/or part-tim.e).* have hired the sub-contractors
listed on the attached sheet 7. 0 Remodeling
2.112 I am a sole proprietor or partner-
These sub-contractors have
• ship and have no e.,loyees •8. 0 Demolition
working n:giloyees_andhive workers' _. _
king for me in any pacity
ca. 9 0 Build asIdition
_ compt.insurance_f__ _ • ___ _ _ _
[No workers' comp. insurance
requirecLJ 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. 0 I am a homeowner doing all work officers have txercised their .
11.0 Plumbing repairs or additions
myself [No workers' comp. Hen of exemption per MGL
12.0 Roof repairs . -
insurance required.] t • c. 152, § 1(4), and we have no •
. employees. [No workers' 13.0 Other
• • comp. insurance recpnred.j
*Any applicant-that checks box #1 must also fill out the section below showing their workers' compensation policy infonnation.
t Homeowners who submit this affidavit indicathig they an doing all work and then hire outside contractors must submit anew affidavit indicathag such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractcns and state whether-or not those entities have
employe. If the sub-contractorshave employeee, they must provide their woriners' comp. policy number. -
I am an employer that is providing workers' compensation insurance for my einployees. Below is the policy and job site
informtrtion.
.
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 tinder Sectiiiii'25A c 152 can lead to the ifiipOsitiini of Critainaj 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-0_17.DM and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
InVestizationi &the DIA for iniurance Cove verification. _. . ... „ , _ , ,,, _,_ .
I do hereby,certzfir under tkpainsand penaldes ofperjury that the &for:natio' n prwvidedabovr_ e_rold_corre
Siat rt __
gnure : / .
___________ , • — D ate 1 1 6 ' — '
. .
Phone it:
. - Official use only. Do not write in this area, to be completed by city or townOfficiaL
• City or Town:
Permit/License #
Issuing Authority (circle one):
.- ' _ _
:1. Board of Health 2. Building Department 3. City/Town Clerk .4. ElectricalInspector 5. Plumbing Inspector
6. Other
Contact Person: '
Phone #: k-• . . •
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ( Not Applicable ❑
�
Name of License Holder : r r \ L ` G `' � 4 6 4442--)
License Number
, fk k V--a- 1.(z t3
Address Expiration D Da
Signature Telephone
9.;R tilstei eiiaHt�ri a mpi �retrfent Conti c or =.. . _ Ki . .; linigaizakESIt Not Applicable ❑
T c 164-iaat
Company Name Registrati n Number
t (1
�
Address Expiration Da e
Telephone
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 ❑
The current exemption for "homeowners" was extended to include Owner - occupied Dwellines 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 buildine 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
R."
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition El New Signs [O] Decks [p Siding [0] Other [0]
Brief Description of Proposed L
-
Work: r &. • 'D t e t. � os,,
x � G — r t o P to►S e-/ t t f • S l a .( S.> — . Kct..) rc too
Alteration of existing bedroom Yes No Adding new bedroom Yes )K No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa Ne a and $a dIi lo'n t e ti ci.ho iiii:aii ifikatieltartiiiiiiiiii
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
g rthd. k - Vkt t t
1, , as Owner of the subject
property n
hereby authorize ' V \ 4` v "`
to act o behalf, in III matters relativ to w r]c autho • ed by this building permit applicati n.
.!_ ' � LL- c \ 1 c . i
Signature of Owner Date
1, si \ Tam V `�' - , as Owner /Authorized
Agent hereby declare that the statem is 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.
E V 1 (.- T C"v13 1"-SL—
Print Name
]" 2 1 0
Signature of Owner /Agent ' 0. e
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 %7
Building Department
Lot Size i 1 ! . .-.- - ... •
Frontage r i I i -
Setbacks Front t j 1 - 1
Side L:.J R: i 1 L: 1 R:1 1 1
- -..._ ? x
d ,
i
Rear
Building Height = = €
Bldg. Square Footage
Open Space Footage @ s %
(Lot area minus bldg &paved i , _ J 1
parking)
# of Parking Spaces
Fill: �.,..�... --- � ,�.�, . . ..�... �. �..��,
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO @ DONT KNOW 0 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 P agel , and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
.9
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained 0 , Date Issued
C. Do any signs exist on the property? YES ® NO
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
IF YES, describe size, type and location: 1
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 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
- „- -
irr ‘F I SPITATISC,.4,": 'atja',;1L- tRP
City of Northampton
„,)* ,k...4.1.& ...
Building Department
4
\ Wi '
iiik 1 al• , ,
# 01\‘ \ \ 212 Main Street
Room 100 „r;P;tzfiw,....10sr77773777:7N
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it -..°";:, ' - '- 7 7 , 17,4 7 7: 6 0,7 , 1`74. z .= ' -
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Northampton, MA 01060 ,/ XZ41:k1500:1;:i
.,,,,,,,,,,,,-,-; `,,,II,:l..:....;.t :41..;,(5.:144,,Zigiitc:-
phone 413-587-1240 Fax 413-587
P lr:,,!tpk'4kt-,':-l--,;rr7-aAt3:'"V"::g7''7'
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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: eiS_c=. \,) e....,, Ni\c. v.,
Map Lot Unit
k ) 0 v - \s”. k 0 \r■ , , -, Overlay District
eim st District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
,C , ,\. (-t----
f
Name ri 7 \ ) r , Current Mailing Address: 1 ....._ g.(0 ,,.__ 70 9 g
, ...
(-e-r- ( - - - s - j-7
Telephon
t i
' \ 1)L C CA- } u-L
Signatur
\ en
2.2 Authorized Aoent:
32 l 3Ork5 A PI
E r i c...- Pa. \A vve.--•
Name (Print)
Current Mailing Address:
1 - 7C0
Telephone
elephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 7, (:),C5e2 (a) Building Permit Fee
(b) Estimated Total Cost of
2. Electrical 2, l o 0 C. Construction from (6)
t
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
.---
ci 6 0
6. Total = (1 + 2 + 3 + 4 + 5) t Clied Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Date
Building CommissionedirlsPector of Buildings
File # BP- 2011 -0596
APPLICANT /CONTACT PERSON ERIC PAYNE
ADDRESS /PHONE 32 BURTS PIT RD NORTHAMPTON (413) 218 -4276 ()
PROPERTY LOCATION 86 VERNON ST
MAP 31A PARCEL 295 001 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
Tvpeof Construction: REMODEL BEDROOM (SHEETROCK,INSULATE & NEW FLOOR))
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 086442 A .� �V�dC( (‚ (A i'�
3 sets of Plans / Plot Plan M a 5T f N = ! A C t E `� � c a nd ( y
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9R'MATION 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
Building Official Date
Signature of u g
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- 2011 -0596
GIS #: COMMONWEALTH OF MASSACHUSETTS
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- 2011 -0596
Project # JS-2011-000960
Est. Cost: $9600.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ERIC PAYNE 086442
Lot Size(sq. ft.): 5314.32 Owner: PHILIPS BRENDA J
Zoning: URB(100)/ Applicant: ERIC PAYNE
AT: 86 VERNON ST
Applicant Address: Phone: Insurance:
32 BURTS PIT RD (413) 218 -4276 0
N O RTHAM PTO N MA01060 ISSUED ON:1/4/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL BEDROOM (SHEETROCK,INSULATE
& NEW FLOOR)) - MUST INSTALL CODE COMPLIANT SMOKE & CO DET
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 1/4/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner