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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
• - • • • - • • I •iocess 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
_peers- in.conjunction.to the_ building.Ternitissued,_ 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.
Address of work
location
r�►
L\ The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations •
®� 600 Washington Street
r =� = 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): /
1. ❑ I am a employer with 4.. 0 I am a general contractor and I
6. ❑ New construction
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. 0 Remodeling
shin and have . no employees These sub - contractors have g_ D Demolition
for me in any capacity. employees and have workers'
working
Y p ty. 9. ❑ Building addition
[No workers' comp. insurance comp. ms �ncp_
required.] 5. [ We are a corporation and its 10.0 Electrical repairs or additions
3.0 Tam- a- homeo-wner-daiag -all work — 9ffi_c_er_ a.ve'4xercis their _ i-J 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. ❑ Other
comp. insurance required ] .
*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
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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. rle advised that a copy of this statement may be forwarded to the Office of
Investizations of the DIA for insurance coverage verification.
_ I do hereby certify under the pains and penalties of perjury that the information provided above_is true_and_correct-___ _ _
Signature: Date:
Phone #: •
Official use only. Do not water in thik area, ta-.be eompfetedbycity or town offciaL
City or Town: Permit/License #
Issuing Authority (circle one):
1.7 Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical I s • ector 5. Plumbing Ins. ector _ _
6. Other y
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: /� Cam/ Not Applicable ❑
Name of License Holder : L�- �pc#v' C / � ( G
License Number
r a.t.49,71.,0
Address Exoir tion Date
Signature
/ 7 Telephone
/
: Reclistered ;Hflinelmprtivement , ,% .,,.. " * „y ..., Not Applicable ❑
Company Name Registration Number
Address Expiration Date
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 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 amp on .• r. finances, a - e : n • • " • s-General- -Laws- Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House Addition [] Replacement Windows Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding [D] Other
Brief Description of Proposed
Work: ,l�vv4� ""t �� ��°,
Alteration of existing bedroom Yes )c No Adding new bedroom Yes > No
Attached Narrative Renovating unfinished basement / Yes X No
Plans Attached Roll Sheet
bar If NeW house and or addition iii exist nca; iiousincq, -coni fete the foilo lii q;
a. Use of building : One Family > Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms 3
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions i{`' b ;A/
e. Number of stories? --- -
f. Method of heating? Cit 47' Fireplaces or Woodstoves �' Number of each
g. Energy Conservation Compliance. Kt Masscheck Energy Compliance form attached?
h. Type of construction - 44.0 -...e
i. Is construction within 100 ft. of wetlands? Yes x No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade C
k. Will building conform to the Building and Zoning regulations? X 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
I,141( ��`_ , as Owner of the subject
property
hereby authorize kdelit-Lo
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
22 8nts ,fy4� , ash /Authorized
9 hereby Agent hereb declare that the statem 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
- 7 - te - V---c> R.6. 770 4. et/15:7/.1.9
Signature of Owner /Agent Date
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
LotSize _ ._ , . __._.__,.,_ ` _ _ ____,. ._._..:
Frontage
Setbacks Front _._,.
Side L:__ R „__ _ ' L _ R: _.._.,.
, i 1 ///) f
Rear ..-
Building Height
Bldg. Square Footage 1 ----- ; % r- _._.. _.._,
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces .._._._
Fill:
(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: I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
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 Q NO 0
IF YES, describe size, type and location:
-- "# - - D: — Tre t ere any p� ropose�lc cha to or a rttons o signs intended for tie property ? YES 0 NO
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 84
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton sta t ` - e� .a tt i� "�
Building Department d ue ttt a �' y er z in �� ,
— -- 212 Main Street Se a �efttlaAvrad - � ,�
Room 100 tg x �t i ra� i l , , 3 t4 r � a
2 h L Northampton, MA 01060 T ". x1 t
phone 413- 587 -1240 Fax 413- 587 -1272 _ �i " 4 *
J i OtaF D 0 9 ,
,..'eFa -.ewe.. __ _ .47,= a 4. , ig, t 3i C .x..- ';
APPLICATION - TOCON'S UCT, 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
Py q� 9 a Puri Q I �B( Q Map Lot Unit
/ Zone Overlay District
-Elm St. District CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of ecord: ;
Name (Print) Current Mailing Address.
1 ae4'1 �` 14 l/(7 /-6 y Telephone
Signature
2.2 Authorized Agent: , l /�
l d to/A / C t1 t L t� g 2 7 5- Y I 'A` YID
Name (Print) , Current Mailing Address:
it /ems -' '-")1L,- ,� t
Signature ' Telephone ,. .- y frbd — Vy( - (
SECTION 3 - ESTIMATED CONSTRUCTION! COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (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 "w
3 +4 +
6. Total = 1 +2 +5 0 0 0 Check Number � ._
This Section For Official U s e Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File # BP- 2010 -0650 N PC_
APPLICANT /CONTACT PERSON THEODORE D TOWNE
ADDRESS /PHONE 75 PARSONS ST APT V EASTHAMPTON (413) 527 -9060
PROPERTY LOCATION 792 RYAN RD
MAP 35 PARCEL 154 001 ZONE SR(100) / /WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out _ � i
Fee Paid a ' 0 c * Ir&
Typeof Construction: CONSTRUCT FULL BATH IN BASEMENT,1 /25/10 - FRAME & INSULATE INTERIOR
WALLS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 000724
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
1L,/ /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 r
1 / 2 6116
Signature of Building 0 ficial Date r
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.