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DEPARTMENT OF BUILDI.\G INSPECTIONS l_=
212 Main Street • Municipal Building
INSPECTOR
Noriliamptati, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3A to
act as 1.is/her construction supe_ . :nor. 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 any 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 occupancv
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
r quired can DELAY the project until such time as the proper permits and inspections are
ade
r
I, understand the above.
(Home own r/re ' ent'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 of Massachusetts
i Department of Industrial Accidents
W� Office of Investigations
600 Washington Street
Boston,MA 02111
°'� s�•'4 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Conti-actors/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):
1.0 I am a employer with 4. 7 1 am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have S. 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.❑ I am a homeowner doing all work officers have exercised their 11.0 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.]
---;:O t y ap i scan a c ec ox must also out a sectron a ow s ovnng eir wor 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I o hereby certtfy under aims and penalties of perjury that the information provided above is true and correct
SiEnaturel v�
Phon
vfficiai 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
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9-Registered 1+6rne.IhJyr6veine6f Cairrfractor::`i r. 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...... ❑
I1.r=:Home.Qner�gernptia»
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-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 w °
r
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [-1 Addition [] Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [o) Decks [M Siding[O] Other[E j
hef Descn tion of r posed
Work: %= l (,. /' i'►2/ ` 'd ��
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6--if lions and or additidh t tie}#otto Aria:
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 o. s cons ruc ion wi i 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
I, as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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.
Signed under the pains and penalties of perjury.
Print Name 1 Q G'V ylv
J J
Signature of Owner/Agent V Date
t
*� ^
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
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&pa-ved
#of Parking Spaces
(volume&Location)
A Has a Special Perm it/Va i noe/Fndi ng ever been issued for/on the site?
Alp 90N7 KNUM YES
IF YES, date issued:',
-----'---'
IF YES: Was the permit recorded at the Registry ofDeeds?
NO \_� DON-r ~."°"" 0 .E^
IF YES: enter Book P age� / and/or D ooum ent#'
�� �� ��
B- Does the site contain o brook, body ofwm�rorwot|an�? NO v�� DONTKNOVV �~/ YES �~/
IF YES, has o permit been ur need to be obtained from the Conservation Commission?
Needs tobeobtained v~~� Obtained �~^~~�� Date �s�ued� � /
�~� ' �
C. Do any signs exist on the property �� ��� YES v�/ NO v��
IF YES, describe size, type and location:
D. Are there any proposed changes toor additions ofs|gnsintendedfortheprnperty? YES NO 0
IF YES, describe size, type and location: }
E. Will the construction activity disturb(clearing,gradingexcavation,nr@|ing)over 1 acre orisd part ofa common plan
that will disturb over 1 acne? YES ��� ) NO ���}
|F YES,then a Northampton Storm Water Management Permit from the DPW is required.
f?epartsneni ase 0
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City of Northampton Statu�al�ermit
-'° � - uiding Department C rtvewa men
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212 Main Street eptt abt[rt
Room 100 ater[1 T61[-A ifgbrt y
�r Northampton, MA 01060 Tr�vo Sets ofStrrrc€iarat Ptans
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v 2 prone 413-587-1240 Fax 413-587-1272 PtoS�fe Ptana � " z
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y OtfierSpee�fy _:v �° r
APPLICATION TO CONSTRUCT;ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
ECTION':1 -SITE INFORMATION
1.1 Property Address:
This section to be completed byoffce
tot ttnEt
One;A/ Z eria 7rstcct
strict::_
E DiGB D�strtcf
rm:St. _._
SECTION 2-PROPERTY OWNERSHIPJAUTHORIZED AGENT'
2.1 Owner of Record:
Name(Print) l.g �lJ ���/� Current Mailing Address:
Telephone
Signature � �—
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATEDr,CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by ermit applicant
Building ; q)Building Permit Fee
r
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) Check Number
This Section For Official Use Onl
Date
Building,Permit Number.. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2008-0211
GIs#: COMMONWEALTH OF MASSACHUSETTS
W" 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-2008-0211
Project# JS-2008-000329
Est. Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: - Homeowner as Contractor
Lot Size(sg. ft.): 14984.64 Owner: PRYSTOWSKI JOHN L&ELIZABETH
Zoning:URA Applicant: PRYSTOWSKI JOHN L & ELIZABETH
AT. 415 ACREBROOK DR
Applicant Address: Phone: Insurance:
FLORENCEMA01062 ISSUED ON:812912007 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 8/29/2007 0:00:00 $25.005041
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo