35-050 (3) 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 occui,ancv
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
liermits 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
,- a- t _ �
L\ The Commonwealth of Massachusetts
- Department of Industrial Accidents
i* -
- M' Office of Investigations
i, 1 ; 600 Washington Street
Boston, MA 02111
' I www.mass gov /dia .
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information n Please Print Legibly
Name ( Business /Organization/ladivitnaI): 69- /e. ,r 57 4.x / ( ( C J P
Address: d v�
p 01(1 • � 5 '7j 7
: ; �� � , r � it �r Phone. # : Jrl �
City/State/Zip:
Are y an employer? Check the a propriate box: Type of project (required): //
1. I am a 1o. er with `'r' 4 0 I am a general contractor and I
y l 6. 0 New construction
employees (full and/or part-time).* have hired the sub- contractors
2_Q I am a sole proprietor or partner-
listed on the attached sheet 7- ❑ Remodeling
ship and have no Ioyees These sub-contractors have .8. Q Den olition
wor� 6 for -me man employees and Kaye workers' 9 Q Buildi ` addition
t � t � r o � y ��� comp inettra79r.� # .. _ _
l� workers'- comp. *trance
5- 0 We area corporation and its 10 Q Electrical repairs or additions
3.0 required.] officers have xercised their . 11- Plumbm repairs or additions
I am a homeowner doing all work , ❑ g eP
myself o workers' co right of exemption per MGL
ys [N comp. 12:Q.Roofrepairs
insurance required] t • c. 152, § 1(4), and we have no .
employees. [No workers' 13.0 Other
comp- insurance requited - }.
*Any applicant Shat checks box #i must also fill out the section below showing th h workers' compensation policy information:
t Homeownc who submit this affidavit .indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such_
1- Contractors that 1-4b;--k this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub- wntcactors have employees, they must provide their workers' comp. policy number-
I am an employer that Ls providing workers' compensation insurance for my employees Below is thepolicy and jobsite
information. -
Insurance Company Name: " I--. //g , M c.) 7.-1).4 ( L dl f ; • •
Policy # or Self -ins. Lic #: /0(:-''' — ..3 1 .-. 3 /7 9 i "r / r i 1
nation Date: - CT ,.5" 1 v �'. o�0 l)
/
Job Site Address1 15 l ,F, � City /StateiZip. r /JX c>0 C 4. ,� - � �
Attach a copy of the workers' compensation policy declaration page the policy number and`exliration date).
Failure to secure coverage: as required' ender Section "25A 'of MGL c 152 can lead to the iiuposition`of cr`iininil penalties of a
fine up to $1,500 -00 and/or one -year imprisonment, as well as civil penalties in the form Oa STOP WORK ORDER and a fate
of up to $250 00 a day against the violator Be advised'diat a copy of this statement may be forwarded to the Office of
Investigations of the DIA for - insurance' coverage veizfication: 77-'-'-'7----:-. _ I ado hereby certify under the pares and penalties of,_perjrny that the information provided nbove_i true_ cnrr - ect _.__. _ - _.
Signatur --h- A --i ; _- Date:
Phone it: Cj if•', .- 4//1C7 .. • .
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town: Permit/License #
Issuing Authority (circle one):
:1. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical ,Inspector 5. Plumbing Inspector
6.Other P
■
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : G '�� �' 10 L 4o7'
License Number
91 1 0 Q 0
Address Expiration Date
G i7/ 4m T M- - 010 10 o —d 7-
Signature Telephone
q'4J
S. Reaistertl lmtfror+etrrenEl r cintrar ..� v9leg ''g E.. Not Applicable ❑
Company Name Registration Number
Si iAv / 'JO `'
Address „.” Date
U Expiration
rr�� �' � � Oil 6 _ 1
/ S/ ' - P / ut A 77 - 6D k4elephone 5R: t 64 / �j �✓G 0 /
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affida it must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil ' g permit.
Signed Affidavit Attached Yes No ❑
F _
iV410 tI a
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 O
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [ Other [0]
Brief of Proposed 4)3 / / 4 / / � J p , I ' I J �)
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6 iLitk ril O tse~ nd" t adds a etii .. iiiq:, li vlta> iiliiia:
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. Masschedc 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
1/1)((/,'/ TO 1) l` , as Owner of the subject
property
hereby authorize > /-*1t2 o is) J 13/2- 1
to act on m alf, in all ma rs r ative to work authorized y this building permit application.
Signature of Owner Date
I mo/ 4 ); k) L /7 , as BwnertAuthorized
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.
Pe, 0 (_ 13 /2,4 /cy
Print Name 7-- �� � � j
sue. 4 t
Signature of OwaedAgent Date
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 i = . i 1
Frontage 1 1 1 1 1 I
Setbacks Front l i = i 1
Side L: R: L:i . R:# ' I i
Rear
Building Height r i
L Bldg. Square Footage = l % 1 = ;
1
Open Space Footage %
(Lot area minus bldg & paved ; ._ _ I D = ,
parking)
# of Parking Spaces = '
Fill:
(volume & Location) t £t ;----
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
1
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 age l ' and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q 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 0
IF YES, describe size, type and location: 3
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q
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.
a
City of Northampton „
Building Department
4 2011 212 Main Street
Room100 ', t. - „,Y,� " °”
1Wo mpton, MA 01060 T r '°$ ; , ¢a
phone 413-M7-1240 Fax 413 - 587 -1272 ,, .
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
ra jq A Map 'Lot Unl
If (,L' Y 444 0)0b.9-) = Overtay Distr ct
EIm St District" CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: WO w
Name (Prin Current Mailing Address:
,/ /-��� Tele hone N �,
Signature r s °' 7 4. 7 6 �, ] /�
oIV 4
2.2 Authorized Agent: 7 ?
Name (Fiat) 1 Current Mailing Fiddress:
Signature Telephone
SECTION 3 - 'ESTIMATED CONSTRU ION COSTS
Item Estimated Cost (Dollars) to be Offic Use Only
completed by permit applicant
1. Building s= (a) Building Permit Fee
s�;O
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)`fO Check N umber � (O
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
BP- 2011 -0607
GIS #: COMMONWEALTH OF MASSACHUSETTS
•
5 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 -0607
Project # JS- 2011- 000971
Est. Cost: $5040.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R SIDING 026846
Lot Size(sq. ft.): 14897.52 Owner: RUBASHKIN MARIA & MICHAEL P & CONSTANTINE A RUBASHKIN
Zoning: SR(100)//WSP II Applicant: B & R SIDING
AT: 966 RYAN RD
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586 -4167 Workers
Compensation
N O RTHAM PTO N MA01060 ISSUED ON:1/4/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL VINYL 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 1/4/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner