38B-168 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
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
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! 1
— —x = Department of I dustr ial.- accidents
-
Ofice of Investigations
600 TYashina ion Street
Boston, 11/14 02111
www. tnass. Gov/Via
Workers' Compensation Insurance ..ffda Builders/Contractors/Electricians/Plumbers
ADrJlicant Information ( / Please Print Lesibly
Name ( Business /Organizadon/Individual): t/ (lj. r� ' 6J 2dd
Address: (Cl Lk '7 60 1) Fi iii. 6,1 1 6)l3
city/State/Zip: Phone r:
Are you an employer? Check the appropriate box:
1. ❑ I am Type ofproj •ct (required): I
4. 1 am a general contractor and I
�i a employer with ❑ 6. ❑ ew construction
nloyees (full and/or par: - time).* have hired the sub contactors
I o a sole proprietor or partner
listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ lam a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
1 _ ❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
i comp. insurance required.]
Any applicant that checks box #1 must also fiII out the section below showing their workers' cornpensation 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 state whether or not those entines have
employees. lithe sub - contactors have employees, they must provide their workers' cortir. 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: 435 o(
Policy 4 or Self -ins. Lic. 4: Expiration Date:
Job Sire 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 crminaI penalties of a
fine up to 31,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S 250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLA for insurance coverage verification.
I do here ', i , , e he pains and penalties of perjury that the information provided above is tru d correct.
II
1 Siznature i / Date: '
G
Phone 4: ?
1 O (0 3
I ,
1 Official use onll:. Do not write in this area, to be completed by city or town official
City or Town: Permit/License n
Issuing Authority (circle one):
1 1. Board of Health 2. Building Department 3. CiryiTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
I 6. Other
i
i Contact Person: Phone
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Super/tsar: Not Applicable ❑
Name of License Holder :
License Number
kddress - Expiration Date
Signature Telephone
l-. R'euister_ed Home lrtrnrovemerre Canti=actar Not Applicable ❑
�fC e) d I/
�� c � ,
�dt't(Y�l �,(1ryld ���, ..,u„�..x._�..._.. .�.�w. .�.., _,.� ,,.., Reisirafion Number
.om try Name g
Po 60i 10 ) 7/07
.ddress Expiration Da
f J d ONO Telephone igll/
ECTION 10- WORKERS' COMPEMSATlON INSURANCE AFFIDAVIT (114.G .L. C. t52, § 25C(6 »)
1
Porkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit..
aned 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. CIVIR 780. Sixth Edition Section 1083.5.1.
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 -vear 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
,. 1
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House I Addition Windows Alteration(s) n Roofing l I
Or Doors
Accessory Eidg. Demolition New Signs [DI Decks [E] Siding [DJ Other [pj
Erief Description of/Froposed , 1 , , shwa- (er
Work: , 7t" 1!' c "l ( 1 3 fi2 14Pd . ilikk rl [ wa
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes Nc
Plans Attached Roll - Sheet
sa If Nerir house gird `oir addition to - is tiiO fiousitia, como(ete the`fa[towinq:
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? /e
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. flocdplain 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 SE C OMPLETED' WHEN
OWNERS AGENT OR CONTRACTOR APPLIES -FOR BUILDING PERMIT
/ I, L aim. C-- 6I, , as Owner of the subject
property
hereby authorize L A L ftI PO c PIA 6
to act on my behalf, in al matters relative to work authorized by this building permit application.
WO V
Signature of Owner Date
I — _titLei1a , 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.
Slone under the pains and penalties of perjury.
Fnnt Name
J TJj tkj LL,
S gnat,_re of Owner„ -'cent =ate
Section 4. ZONING I 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 _......... __
Rear ___ _ .____.
Building Height A-- -_
Bldg. Square Footage _.. _ %._ _. _ _...,
Open Space Footage __
(Lot area minus bldg & paved ,___, _ . _ _
naridne)
# 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 Q
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 Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained ,Date Issued:
.0 C. Do a 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 0 NO 0
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 Wale {ManagemenfPermit from the DPW is required.
t , Depart ment use only
� \ L . � ', City of Northampton Stags of Permif
. , i
i, Building De Curb Cuf/Qrtveway Perin
it
212 Main Si eet S ewer /Septic Ava
2 0 200B Room 100 Wate Ava
.
M �Y N orthampton, MA . 01060 Two Sets of Structural Plans
alone 413 -87 -1240 Fax 413 Plot/Site Plans
C;TIONS Other Specify
- - -- APPLi�ION TO CONS T RUcT, 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
•'] F Sr Mp Lot Li0 A V )111A p'od Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
CPL- (ik.06 5 35 r 5t
ame (Print) Current Mailing Address: 1.4 /� � p� /' �
a d z ,lsi
Telephone
Signature it I3 (�J 7 O
2.2 Authorized Agent:
a lloy IT 11/S poo F1146 0 60 { 07 su i)P /A
Name Pri Current Mailing Address:
1 ci/3 776i � y
Signa u r Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS 1
Item Estimated Cost (Dollars) to be Official Use Only
moleted by permit applicant
1. Building y)e)
(a) Building 'PermitFee
2. Electrical ` l d (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) 5OOO ( Check Number ��
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
-- -- — -- — — — — l
Buriding Commissronedlnspectoro buliomgs Gate
BP- 2008 -1047
GIs #: COMMONWEALTH OF MASSACHUSETTS
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- 2008 -1047
Project # JS- 2008 - 001551
Lst. Cost: $5000.
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HAWKINS ROOFING 113957
Lot Size(sq. ft.): 5183.64 Owner: MOOS CARL & JOAN MOOS
Zoning: URB Applicant: HAWKINS ROOFING
AT: 38 FORT ST
Applicant Address: Phone: Insurance:
P 0 BOX 107 (413) 774 -6834
SOUTH DEERFIELDMA01373ISSUED ON:5/20/2008 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 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 5/20/2008 0:00:00 $25.0014442
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo