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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 •ro_cess 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
- - -- -- --- perms- in- conjunction_to- the- buildi g_permitissued,_and_ 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
,..! 14 — ( Office of Investigations •
600 Washington Street
Boston, MA 02111
,;. . www.mass gov /dia •
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
•
Name (Business/Organization/Individual):
Address:
City /State/Zip: Phone. #:
Are you an employer? Check the appropriate box: Type of project (required): i'
1.0 I am a employer with 4.. 0 I am a general contractor and I 6. 0 New construction
ki employees (full and/or part-time).* have hired the sub- contractors
2 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
,hip and have. no em These sub - contractors have. g_ 0 Demo, iriion
working for me in any capacity. aci employees and have workers'
, 9. 0 Buildin addition
[No workers' comp. insurance _ comp vran
..insre.+
required] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am- a-homeownerdoin ork-- - - -• -- ce -have exert ed heir - -i-1.C1 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' 13.0 Other
comp. insurance requited./
*Any applicant that checks box #1 must also fill out the section below showing their workers' 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_
$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 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
in_ formation
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 $1 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. fle 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 pen plies ofperjury that the information provided.above is true.androrrect. _ _
Signature: Date;
Phone #:
f O f c i a l u s e o i i i y . D o n o t w i n e i n this area, t o be completed by city wn o c aZ
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PlumbingInspector
6. Other
Contact Person: Phone #:
,, SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Constructio/ Supervisoo :: q [/�
�� 4 I Not Applicable ❑
Name of License Holder : 7 `-'' / "' / ' C 5 7 `- f L
License Numb r
'/ r of /t / . .. 2f
Ad Expiration D e
.41 (4--
Signa ure Telephone
.9.., Registered, Honie;lmp"roueruentCont x, .it ;;„,t ,. &,..`y ,,h .; Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
_SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) J
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 ❑
xi s ' �. ' k ®. I ,, ', 11 I " ] M
T_he_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
o ampton e r o trig ces a e, 4 o :- sGeneral -- 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 [D] Decks [C] Siding [D] Other [D]
Brief Description of Proposed j /
ork: �/ r L V � Gch) j � �% ' e aR�u■
/ /
Alteration of existing bedroom Yes No Adding new bedroom Yes k No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a1' Cf sltif w `I Ouse nd.+ r..= addition.to exrsttnq hogsll�q;: GOmpl`ete the fia lo�iv n :
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
'v l r -, V VIux , as Owner of the subject
property j(45
hereby au orize / • G?" l %
to act on y be 1ri rolr' ers r• - iv to work a,�r orized by this buildi g permit appli • tion.
/ • ! J 3 pGt'
Signatur- of V, j Date
I, , 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.
Print Name
Signature of Owner /Agent Date
N
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 s ____ r` "�""T % i r F
Open Space Footage %
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill: 1
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 44* DONT KNOW 0 YES
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 e Pa and /or Document # ry
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 Conse ation Commission?
Needs to be obtained 0 Obtained , Date Issued
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
0.-Are there proposed changes to or a dditions of signs m��` ten ed" o the property ? Y ES (3 NO O _
IF YES, describe size, type and location: U'
E. Will the construction activity disturb (clearing, grading, -x - vation, 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.
•
l '� - a� p ?
City of Northampton Staiu of-P �� ,
Building Department til u tiD �tewayPe , . 4 44 . 4
212 Main Street Sew ep fic t Arattat 6i 4. 6
Room 100 Wa le e'i,. - _ ��`10 <O `
Northampton, MA 01060 � �ts�a °a� I �. �;
phone 413- 587 -1240 Fax 413- 587 -1272 "t/Si a an
r. � z z
Ctl 1
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLIS A ONE O O FAMILY DWELLING
SECTION 1 -SITE INFORMATION
` L.
AUG 1 1 2009 I
Thi secti6n..to- be•cp 00eit protfice
1.1 Property Address: or r" O P
q .,, . - " tl 6G
ti/L #t c-,0 L i U
- j Map nit
Z<t ► A„,.... A �i 'Zane Overlay District
QUIXaC
Elm' St ' District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
--_
Nam �(; � / / / / I Cur Tele r We
Mall�ng A�3 OO
I!! '' _"L . . . . _ p on
Sig
2.2 Authorized Agent:
1 ' it-- 4 PI, 2C (171 57 7 _e S'7 - /�l :/r im
Name (Print) � ) Current Mailing Address:
4, z� L i/3 -ri q --- /Fl
Signature Telephone
SECTION 3 - ESTIMATED COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building l p. J4°u �"} (a) Building Permit Fee
--
2. Electrical CT �� �' (b) Estimated Total Cost of
Construction from (.6),
3. Plumbing ( L.r17 ° Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection it-
6. Total = (1 + 2 + 3 + 4 + 5) 0—(3-C '11,- 124
C heck Number
This Section 'Far—Official Use Onlq
Date
Building Permit Number. Issued:
- - -
Signature: Off/i1' 09
Building Commissioner /Inspector of Buildings Date
—
File # BP- 2010 -0166
APPLICANT /CONTACT PERSON ALAN A MARTINBEAULT
ADDRESS/PHONE 517 FEDERAL ST MONTAGUE (413) 367 -0266
PROPERTY LOCATION 9 WALNUT ST
MAP 32A PARCEL 016 001 ZONE URC(l00)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out /1020 ` Fee Paid 0 J
Typeof Construction: REMODEL KITCHEN, ADD CLOSETS,WINDOW
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 86044
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
-- 6 1/30?
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.
9 WALNUT ST BP -2010 -0166
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 016 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-2010-0166
Project # JS- 2010 - 000205
Est. Cost: $20000.00
fee: $120.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ALAN A MARTINBEAULT 86044
Lot Size(sq. ft.): 3310.56 Owner: MUERLE LINDA & BURT EWART
znninu_: 131:(2(100 `,/ Applicant: ALAN A MARTINBEAULT
AT: 9W,\LNu1 I
Applicant Address: Phone: insurance:
517 FEDERAL ST (413) 367 -0266
MONTAGUEMA01351 ISSUED ON : :8i14,/ 009 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL KITCHEN, ADD CLOSETS,WINDOW
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: ,6 if a, lJ • 09 - � . / CG
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: , Insulation:
I ii al: Smoke: ' Final: Qr.t<74112 r dL 1
x r6
T IS F ERMI � 1N;t Y B R YO B = THE C IT Y - OF, N 3AM'P UPO y -° sOF 44 ANY OF IT PULES AND REGULATIONS; I - '
r
IV
`f' / Si nature '
Certificate of Oc cupanc f
I- ee S ,n e; Date Paid: Amount:. . -
�. .�.. �� ,� 1 p ,., �:� y
Building ' - 8/14/2009 0:00:00 $120.00
r
212 Main Street, Phone (413) 587 -12;0, Fax: (41.3)537 Building Commissioner - Anthony Patllp