35-092 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
iermits 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
k 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
1
•,.
The Commonwealth opfassachusetts
_,- Department of Industrial Accidents
A lk .m.....■ ffd
,5 1#='; r Office of Investigations
600 Washington Street
Boston, MA 02111 •
- , www.mass aov/dia • .
, •
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers .-
Applicant Information Please Print Legibly r
t
Name (Business/Organizatiodrjdual): ,) 1 ivvvej J
• Add;;;;:it
City/State/Zip: Lad 3 AAA - O/C 53 Phone.#: y/,' 3 z 7- Y AID
1
Are you an employer? Check the appropriate'box: - Type of project (required): .
• 1.0 I am a employer with 4. 0 I am a general contractor and I
6
employees (fill and/or part-time).* have hired the sub-contractors . 0 New construction.
listed on the attached sheet. 7• 0 Remodelinz,
2.0 I arn a sole proprietor or partner-
ship and have r_o employees These sub-contractors have. . 8. 0 Demolition.
any capacity
workng for me en_vloyees and have workers'
i m
[No workers' wrap. insurance
10.0 Electrical repairs or additions
. 5. 0 We are a corporation and its
3. 0 I am a homeowner doing all work officers have4xercised their .
/ 11.0 Phi:tubing repairs or additions
myself [No workers' corap. right Of exemption per MGL
12.0.1t.g . •
insurance required.] t - c. 152, § 1(4), and we have no
employees. [No workers' 13.1=1 Other
comp. insurance required.]
*Any applicant .that checks box #1 must aLso ffil 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.
1 C-ontmctors 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-contractorsbave employees, they must provide their workers' ccorm. policy number.
.
-
lam an employer that 'is providing workers' 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 requited Mid& Sectiiiii c. 152 can lead to the iiiiPositiori olefin:1:W 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 WOIZIC-ORDER 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
ht7eitikatimis &the DIA for iiisurice covirize iriiificiticiii. -
_ Ido hereby_certifr under_thefains-and penalties' • ofperjury that the information provid e dabove_iitrue_Und_Correct _
A .5' -- . /- •
/ / ,
Phone #:
• t rg - - • •
. - Official use only Do not write in this area, to be completed by city or town ojrzcial
City or Town: .- Permit/License # ' .., _ _ .
Issuing Authority (circle one): -
: Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other , f- . .
Contact Person: Phone #:
•
...
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder : M� L l��• l 0 S!
_ L Number 1--/.5"---tz----
Pb Bo)(t L MA oids3 Add
Expiration Date
' <' ice-
Signature G Telephone
L Recliste " 1 ki tte 1M r# cetriitiitCoi>fi'actbr ';� ._ , : , ;� ,. Not Applicable ❑
�� .4., Lx- - _ !79 Z ge
Company Nam � Y a � I � C / � Registration Number
l
A tion ate
Address Expir
LeedS` 061-5 Telephone' '7 3 P�
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G,L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be com feted and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building pe ' .
Signed Affidavit Attached Yes No ❑
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
i
SECTION 5- DESCRIPTION OF PROPOSED WORK! (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) 0 Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [0] Other [0]
Brief Description of Proposed i / %
Work: nIA t' L- Otie
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
. 3 ] go i houS aIIr r adC O . iimir rnu i1� iiii i '1 ]]ii!lill` 0 ,:
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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ‘Leii( / ` // (fy,= y , as Owner of the subject
property /
hereby authorize / <4(0 ?` ZUCt..L..._
to act •n my b = in all matters rela ive to work authorized by this building permit application.
• ignature of Owner Date 4 / . p
l 47...0,_ ,,,� �� , as Owner /Authorized
Agenereby d re 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.
It. fi ). 1---L w—
Pri a
/2, I/
■
atur Date
•
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To I comitet rrifbrniatioti
Existing Proposed Requ red by Z"
This cplumn to bailie is
Building Department
Lot Size __ _ 7- -.. �.
Frontage 1 ,
Setbacks Front I
Side L:l ! R:1 L:` 1 R:` ._,J r ,
Rear
Building Height s
Bldg. Square Footage '" ""--1 I % i 1 i 1 1 s
9
Open Space Footage %
(Lot area minus bldg & paved ; I i F 1-1
parking)
# of Parking Spaces I _ __ .
Fill: ; .•.- .,..,.°.. _ _ 71 ____ _. �.. _ , ._, ,,._ ... _� ___ _,
(volume & Location) ,_
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 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 j i Page and /or Document # �
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q ,Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0
IF YES, describe size, type and location: e
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
4
a.
p
>, V D it y ' Northampton �Oe z�,, 1 �j
uil • ng Department .-' t tl - �t;�ti 0
- fill 13 Jfl 21 Main Street p _ r
if
oom 100 `° f .
ha ton, MA 01060 P : ' = -i.'"
OFetNIDtNG ^NSPE ` :,.,it, - : 1240 Fax 413 - 587 -1272 8 = ° ` , ,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Pro a Address:
This section to be completed by office
1 3 r30,,-) Pit— M ,
,Map Lot Unit
Zone Overlay Distract
ELM St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
7 /1)(isf/i Z. N y //73 /s%7 -0/
Name (Punt) / Current Mailing Address: / / /
J,n /[ /1(X .rL
Telephone
i i tune
2.2 Authorized Agent:
j ;; 3. L.Li- PO (,9xs l y
Name (Pri Current Mailing Address:
•
seir i ii 3 i )Ye°
cture Telephone
SECTION 3 - 'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 3 1 5 i) Q- (a) Building Permit Fee
i
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection )
pt
6. Total = (1 + 2 + 3 + 4 + 5) 3 i (. �� Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: S—/ / /
Building Commissioner/inspector of Buildings Date
1173 BURTS PIT RD — BP- 2011 -0945
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 - 092 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP-2011-0945
Project # JS- 2011- 001543
Est. Cost: $3150.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY J LUCE 100515
Lot Size(sq. ft.): 8668.44 Owner: FENNESSEY KAREN L
Zoning: SR(100) / /WSP II Applicant: TIMOTHY J LUCE
AT: 1173 BURTS PIT RD
Applicant Address: Phone: Insurance:
P 0 BOX 14 (413) 387 -9800
LEEDSMA01053 ISSUED ON:5/17/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:SHINGLE ROOF OVER 1 LAYER
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 5/17/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner