23A-272 (2) HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780C MR 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
permits 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 me.
Date
Address of work
location
�__ The Commonwealth of Massachusetts
-z - Department ofln,ustrial.Accidents
` O of Investiaations
600 TT asking ton Street
_ _- — Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
AD tniicant Information Please Print Legibly
'ame ( Business /Organizarion/IndividuaI � ' " t 1 )CCtt CL - 01 - j' C( L !t i 11 t
Address: ..3 E 1 6-Wa 5 1 lam' S - - . 1 - ,
Ci ty. State /Zip: .,_.JZ e. i C ' -- MA. 0I G 4.;Y2 Phone #: t > = ,4 (o 2-5
1 Are you an employer? Check th ppro ate box: Type of project (required):
r
I e �. I a general contractor and I
e . ployees (full and/or part - time).* have hired the sub contractors
214 listed on the attached sheet. 7. ❑ Remodeling
I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. ❑ Demolition
employees and have workers'
working for me in any capacity. 9. 0 Building addition
[No workers' comp. insurance comp. insurance. 6. ❑ ew const action
required.] 5. ❑ We are a corporal on and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work
officers have exercised their 11.0 Plumbing repairs or additions
myself. [No o workers' comp. right of exeluf tion per MGL 1 0 Roof repairs
insurance required.] 1. c. 152, § 1(4), and we have no 13.0 Other
employees. [No workers'
1 comp. insurance required.]
Any applicant that checks box #1 must aiso 511 out the section below showing their workers' compensation policy information.
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 stare whether or not those entities have
employees. If the sub - contractors have employee, 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
information. (
Insurance Company Name: 455 L(Cfr e 1:7 E VKp`oL ere. -5 / v(e1 -C r + £ t? _
Policy # or Self -ins. Lic. T: �� SO 000 "W.90 ( 2- i j. Expiration Date: to /2
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 crirninal 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 ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of rhis statement may be forwarded to the Office of
Investigations of the DLL for insurance coverage verification.
I do hereby certify itnder the pains and penalties of perjury that the information provided above is true and correct.
Signature: _ -, 11` 1 Date: / - a -1
1 ,
Phone : I A ` :') '� ' - ..-1. ^.�
Official use only. Do not write in this area, to be completed by city or tows: o
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
1
j Contact Person: Phone ,,
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : V L° v— ey cAt
License Number
3 Z ?MG (-0 ..er ✓n4 . C 5 o5 31s`)
Address Expiration Date
SE'—E—( ZS I c (3
Signatur� 4 ' Telephone t b
9. Registered Home Improvement Contractor: Not Applicable ❑
( 0 L2 2:1
Company Name Registration Number
Address Expiration Uate
32 Pu n e-- s{" mac. etAcc„, t11\ Telephone 5 ' 4 (2s j
—
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 4 No ❑
11. - Home Owner Exemption
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 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed R•, ired by Zoning
is column to be filled in by
Building Department
,
Lot Size
Frontage
Setbacks Front
Side L:. R: L: R:
Rear
Building Height
Bldg. Square Fo • ge
Open S. - eFos .:
(Lot a - . ' • . .ldg & paved
p. >,
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON' KNOW 0 YES Q
IF YES, date issued: ,
,.
IF YES: Was the permit record:d at the Registry of Deeds?
NO 0 DON'T OW 0 YES
IF YES: enter Book : Page and /or Document #<
B. Does the site contain a brook, body o • wat; or wetlands? NO 0 DON'T KNOW Q YES 0
IF YES, has a permit been or need to • - obtained from the Conservation Commission?
Needs to be obtained 0 Ob -fined , Date Issued:
C. Do any signs exist on the prop -rty? YES 0 NO Q
IF YES, describe size, pe and location:
D. Are there any prop• ed changes to or additions of signs i tended for the property ? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the constr ction activity disturb (clearing, grading, exc ati , or filling) over 1 acre or is it part of a common plan
that will distur over 1 acre? YES Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [0] Other [0]
Brief Description of Proposed F,
Work: `a — r i 1
Alteration of existing bedroom Yes /— No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathroom
c. Is there a garage attachec(?
d. Proposed Square footage of ne onstruction. Dimensions
e. Number of stories?
T
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. heck Energy Compliance form attached?
h. Type of construction
i. Is construction within 1 • : • . o nds? 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 .
1. 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, V7TSC
, as Owner of the subject
property ea-ft
hereby authorize e 'r e.
to act on my behalf, in all matters relative td,work authorized by this building permit application.
Signature of 0 Date 5' 3 c) S 2--
1,
Ji.. O ` , as Owner /Authorized
Agent hereby declare that t 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.
e.Q vTr
Print Name fb
.ratiLit .�>i� — cl —
Signatu ni -nt Date
T '
City of Northampton �i
Building Department
"'
y i�� ' '' t # n �` 7.0 4i.
212 Main Street - ' "
�' Room 100 4 �
\y /��NS ? ° :. ,iii
\r �pEC Z orthampton, MA 01060 a� - ) t ; o r o o
F B ��� oN one 413- 587 -1240 Fax 413- 587 -1272 ®� 5 : a
fit,
01:N0 ..sue. 114 ...,,�
I 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
3t -33 Crl g L map Lot Unit
yk
t � d
�(„•,� (/‘ Zone Overlay District
Eim St = Dtstridt ` ?{ 'GB District `" . .
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
y Telephone
� � �
Sign `�T �
2.2 Authorized Agent:
Tejr- �. B " . 7_. PINE, ' Name ( Pri) 1 Current Mailing Address:
1 ..f F"Cl 5‘S Ga.6 i
Signlu 11 • Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 2_ (a) Building Permit Fee
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) 2 — Cfr Check Number ,,5 k or, ,5,5--
This Section For Official Use Only
Permit Number: Date
Building Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
31 MIDDLE ST BP- 2013 -0447
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A - 272 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2013 -0447
Project # JS- 2013- 000716
Est. Cost: $2000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JEFFREY BOTT 053157
Lot Size(sq. ft.): 20778.12 Owner: BOTT JEFFREY & VIRGINIA L MILLER
Zoning: URB(100)/ Applicant: JEFFREY BOTT
AT: 31 MIDDLE ST
Applicant Address: Phone: Insurance:
32 Pine Street (413) 584 -6251 Workers Compensation
FLORENCEMA01062 ISSUED ON:10/15/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE SLATE ROOF
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 10/15/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner