29-319 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 your) 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
required can DELAY the project until such time as the proper permits and inspections are
made
understand the above.
(Home OvAer/resident's signature dquesag exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date Z' ,°2" 4
Address of work
location q" C rehrltlo
Dl4(o �
L.�• Tire Cotnmarzwea%t!i of Jlassacnaserrs
Deoarvnen!aflrrdirstrial_4 ccidenms
M _
- O;Tlce of nvesrizarioTts
600 Uushin—ma Srreet
Boston, V4 02111
41x1w.m ass.g ov/dia
«Yorkers Compensation Insurance Affidavit: Builders/Contractors Tlectricians'Plumbers
Am)licant Information Please Print Leaibl,
-anie !$usiness�Or�anizaron Individual): _
Address:
City'State-Zip: Phone,
Are you an employer' Check the appropriate box: F66. e of project(required): I
1.❑ I am a employer with 4• ❑ 1 am a general contractor and I
y ❑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. 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 10.7 Electrical repairs or additions
3.� I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [-No workers' comp. right of exemption per MGL i d.❑ Roof repairs
insurance required.] ' c. 152, §1(4),and we have no
employees. [No workers' 13.7 Other
comp. insurance required.]
*Any applicant that checks box Ti must also till out the section below showing their workers'compensaion 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 entities have
emplovees. 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 r or Self--ins. Lic.;r: 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 5250.00 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 o he�1, ceSignatu
Prone =:
0�ficial use only. Do not write in this area, to be completed by city or town officiaL
City or Town: PermitLicense#
Issuing Authority(circle one):
1.Beard of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
j Contact Person: Phone T:
� � V
ScZTION 8 -CONSTRUCTION SERVICES
I
8.1 Licensed Construction Suoe:visor: Not Applicable ❑
Name of License Holder.
License Number
Aacress Expiration Date
Signature Telephone
j
9.Registered Home lmprovem r:ent Contracto Not Applicable 13
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.
Sioned Affidavit Attached Yes....... ❑ No..-... ❑
11. =Home Owner Egehi tie
The current exemption for"homeowners"was extended to include Owner-occupied Dwellinzs of one(1) or two(2)families
and to allow such homeowner to engaze an individual for hire who does not possess a license, provided that the owner acts
as supervisor.CMR 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-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 a d State of Massachusetts General Laws Annotated.
Homeowner Signature ��
m 4r
SECTION =-DESCRIFTION OF PROPOSED WORK(check a!!aoolicabie+
I New House 1-7 Addition Replacement Windows Alteration(s) Roofing r
I�1 Or Doors P1
Accessory Bldg. Demolition ❑ New Signs [pj Decks [)_] Siding Other[p]
Brief Description of Proposed i� Ar,4JCLd e -h01O/!✓I�f
Worka RfJcKja Azcle' Lv 4A 1 i ' Ae'_J
�'v`�sr b�[( �-old ��" a vim,°h�..•�c� �� � 5 r`c!c c f r.�c�
Alteration of existing bedroom Yes V_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 housin`a complete the fotiowinq-
a_ Use of building: One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
I 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. 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 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
I r'f t- kf ee rfg �CI�/� ja( SL/4' as Owner/Authorized
Agent hereby declare that the slatements 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-
.
iPrint Name // ]/) //� j p y>y
Q.�� /t_�+.v Y✓y y /(XJt. ! 'I(,�.FilC... L
G
Signature of Owner"Agen ate ��
Sect or 1. ZONING Al:information Must Be Completed. Permit Can Be Denied Due To incomplete Information
Existing Proposed Required by Zoning
This column to be tilled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R:
Rear
Building Height
e
Bldg. Square Footage ozo
Open p ce 0
pen Space Footage %
(Lot area minus bldg&paved
Foarkinto
# fPa Parking a,
ofParkinz Spaces
Fill:
(,.I. a L
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON7 KNOW 0 YES 0
IF YES, date issued:---,-,-
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON7 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 DON7 KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 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 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excavation, or filling)over I acre or is it part of common pian
that will disturb over 1 acre? YES 0 NO C)
IF YES, then a Northampton StErrn Water Mdn-agem6h -Permit from the DPW is required.
Department use only
OT (�i@ hampion Status of Permit; I
(t C „� 1 �IC?pa! `?�n Curb Cut/Dtivewa} Permit
212 Ma�ai, Street Sewe7SepticAvailabiiity
ROorh"100 waterfUUell Availability
i `,` 2 rkcArildMpton,, Mr, 01060 Two Sets of Structural Plans
Me 413-587-1240 Fa�. 13-587-1272 Plot/Site Plans
Other Specify
APPLICA T IOWf!- CC)N-$tk#C ,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
Map Lot Unit
r4t�in L � � Zo.ne Overlay District
/"1 Eim St District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
k4enl)o 12:
Name(Print) Current Mailing Address:
Telephone 3
Signature 11 "!Ysv-
�
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-'ESTIMATED CONSTRUCTION COSTS
Item I Estimated Cost(Dollars)to be Official Use Only
completed by permit aoolicant
1. Building IX ( � Q-0 (a)Building Permit Fee
I
2. Electrical (b) Estimated Total Ccst of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) I
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
- Date
Building Permit Number Issued:
Signature:
1 _. ------- --------------^-
I Building;Gommiss,oner/Inspeetoror BuRdings Dale
h
File#BP-2008-1172
APPLICANT/CONTACT PERSON JEKANOWSKI ROBERT P&MARY E
ADDRESS/PHONE FLORENCE (413)584-4882 Q
PROPERTY LOCATION 423 ACREBROOK DR
MAP 29 PARCEL 319 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL REPLACEMENT WINDOWS,FACIA BOARDS SIDING 12" OVERHANG
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
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 D ay
� — �f-�
Signature of Building Of icial Date C��
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.
ti.
M DR,'' B P-2008-1172
GIS#: COMMONWEALTH OF MASSACHUSETTS
"29-,319 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-2008-1172
Project# JS-2008-004727
Est. Cost: $25.00
Fee: $25.00 ' PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Homeowner as Contractor
Lot Size(sg. ft.): 16944.84 Owner: JEKANOWSKI ROBERT P&MARY E
Zoning:URA Applicant: JEKANOWSKI ROBERT P & MARY E
AT. 423 ACREBROOK DR
Applicant Address: Phone: Insurance:
(413) 584-4882 ()
FLORENCEMA01062 ISSUED ON:612612008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS,FACIA
BOARDS, SIDING,12" OVERHANG
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 6/26/2008 0:00:00 $25.004582
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo