29-285 ti
v�
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CINM 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 twofamily
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
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.
Date
Address of work
location
The COf31f7ZQfZYVeQ ,th of
1assacftL.•setls
Department ofIndustriaiAccident-
0,T Ce Of�fZl'eSii�aZiO?ZS
600 T'ashin-ton Street
Boston, ?I1- 0211.17
> -ww.mass.-ov/dia
Workers' Compensation Insurance Affidavit: Builde rs/Contractors,,EIectricians;'Plrtr..bers
A>;alicant Information Please Print Legibly
�'3Illz (Business/Organiw� ion'Individuai;: L e V/'6 -r^ (.� ' ��'R 9S
A�CrcSS: - L/ 7 � V
Cit, 'StateiZip: L >F 05-3 Phone=-X113--,5
Are you an emplover:'Check the appropriate box:
Type of project(required):
4. I am a general contractor and I
1.❑ I am a employer with 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. �I Remodeling
ship and have no employees These sub-contractors have 8. [j Demolition
working for me many capacity. employees and have workers' 9. ❑Building addition
[-'-No workers' comp. insurance comp. insurance-.4
re u rPd. 5. We are a corporation and its 10.0 Electrical repairs or additions
=.❑ I am a homeowner doing all work officers have exercised their I LE Plumbing repairs or additions
myself. o workers' comp. right of exemption per N4GL
�' 1_ 7 Roof repairs
insurance required.] ' c. 152, §1(4),and we have no 13.71 Other
employees. [No workers'
comp. insurance required.]
".Any applicant that checks box#1 must also fill out the section below showine their workers'compensation policy information.
Homeowner,who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Cone-actors that check this box must attached an additional sheet showing the name ofthe sub-contractors and state whether or not those entities have
employees. If the sub-contractors have e•rpioyees,they must provide their workers'corim.policy number.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
..r
iccJ yr tic atiiirc.
i Durance,— pany Name: _
Policy Tor Seif-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 viGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonment, as well as civil penalties in the forn of a STOP WORK ORDER and a fine
oi up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigatiors of the DLz for insurance coverage verifica*.ion.
I do hereby certify cinder the pains and penalties ofperjury that the in�ormation provided above is true and correct.
Signature: Date:
Phone 1: 4 I a'— S8& 7 q ;-,9
I71Jiciul use only. Igo rot write in this area, to be completed by city or town ociaL
City or Town: PermitLicense
Issuing Authority (circle one):
I.Board of Health 2.Building Department 3. Cir_y/Town Clerk -:.Electrical Inspector 5. Piumbing Inspector
{
6. Other
1
i Contsci Person: Phone
SECTirJN E -CONSTPUCTION SERVICES
E.^ Licensed Construction SuoerAsor: .-t e Not Applicable ❑
Name of License Holder, Ld vi�5 ^� ' 6 r AIC-`119 5 ic :5 1
License Number
adcress Expiration Date
;icnature Telephone
I
t.Reciistered Home ImDrovernen#Contractor Not Applicable ❑
ato:omoanv Name Registration Number
?-y q NAy o Eiyy i`1i-
9/-71;.-CC 1
.ddress t, Expiration Date
Telephone
ECTION 1:0-WORKERS'COMFENSA710[4 INSURANCE AI•riDAU1T 4M:GL c.152,§25C(fi])
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.
oned Affidavit Attached Yes....... No...... ❑
wn
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow Such l'iUlrieUwIler to eni a_e an'uid:—:13 ia1 ivr hire wiio dUeS nvt pUSSeSS a license provided that the owner acts
as supervisor.CNIR 780. SLtth Edition Section 10835.1.
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 Derson 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 Dermit.
As actin-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 1533 (Liability of Employers to
Emplovees 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 undersimed"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Nomhampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION DESCPIP T ION OF PROPOSED WORK(check all anoticable)
iNew mouse , Addition C Replacement Windows Alterations) C Roofing
I Or Doors Cl f
i
Accessory Bldg. Demolition I New Signs [pj Decks [L---] Siding Cher jQl i
FE-rief Description of y
k: �/� it ) I 4 ation cf existing bedroom Yes Ne Adding new bedroom Yes /� Nc
hed Narrative P.enovatino unfinished basement Yes � No
A. ached Roll -Sheet
sa.'If New house and or acidrtlon-ta ezistina housina:cor lafet the 40I10416' a:
a. Use of building: One Family Twc Family Other
b. Number-of rooms in each Mmily 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 Wocdstoves Number of each
c. Energy Conservation Compliance. Masscheck Energy Compliance form attadhed?
h. Type of construction
Is construction within 1GO ft. of wetlands? Yes No. Is construction within 100 yr. flocciplain Yes No
j].. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
1. Septic Tank City S e er Fri ate well City water Supply I
ISECTION 7a OWNER AUTHORIZATION—70 SE.COMPLETtU. WHEN- f
OWNER"S AGENT OR CONTRACTOR APPLIES FOR BUILDING PI=KNIT it
as Owner of the subject
property
hereby authorize L- U Jr!;
fto act on my behalf, in all matters relative to work aLlhcrized by this building permit application../
Signature of Owner Date
as Own e r/A uth c rz..d
gent hereby deciare that the statements and information on the foregoing application are true and accurate, to the best of my knowiedge
and belief.
Signed under the pairs and penalties of pe jury.
Prinz dame /
JaiE
JiCf:c Ctlfc-f CWGcr;,-�-.gert
~ ,
^~ °
4. ZONING ALI Information Must Be Compieted. Permit Car,Be Denied Due To Incomptete Information
E:ust,M2 PrODOSed Required by Zoning
This column t'0 be filled in by
Building Department
Lot Size
Frontaze
Setbacks Front
Rea
Building Height
Open Space Footage ed %
(Lot area minus bldg&pav
#of Parkine Spaces
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
ex
� v~-t
NO \^� OONTKNOYY ��� YES ��'
IF YES, date issued:- `
IF YES: Was the permit recorded at the Registry uf Deeds?
NO � ) DONTKNOYY YES~�
IF YES: enter Book Page and/or Document#' �
tit �_��� YES �_���
B. Does the site contain a brook, body of water orwetlands? NO ��/ YY DONTKNO
IF YES, has permit been or need to be obtained from the Conservation Commission? '
Needs to be obtained v�� Obtained �-v_/\ Date Issued:
�------------
\�� '
C. Do any signs exist on the property? YES �-\ NO AX
IF YES, describe size, type and location: �
D. Are there any proposed changes toor additions o[si �
gnsintendcdrtheproperty7 YES 0 NO A�5 ko
IF YES, describe size' type and location: �
E. Will the construction activity disturb(clearing, grading, excavation, ur filling)over 1 acre oris it part ofaconmorn pian
that will disturb over 1 acre? YES ( ) ND
��
IF YES,then'a Ncrtii.���otcnSGo-F�'0Vffe-r Man-a-gem6-infPennit from the DPW isrequired.
s
Department use only
-amity of Northampton Status of Permit:
, `� B,,uiiding Department Curb CutlD veway Perm
r , , 2 r2 Main Street SewerlSepticAvailahitify
ROOM 100 VVaterlUVeil AuailabiErty
2CO�Ierthdmpton, MA 01060 Two Sets of Structural'Plans
�Ane 413-587-12,10 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPQCATION TO CONST'F2UC—j ,�LTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
dd
. - 1 ,FAI G/7 T t. Map Lot Unit
Zone Overlay District
Elm St District CS District
SECTION 2-PROPERTY OWNErZSHIPIAI I-THORNED AGENT
2.1 Owner of Record: F1,0 Etc.
P4-f PaLlli-,JAI EN6r15 Ti-
NamePrint) Current Mailing Address:
Telephone 5-g(D , ld 1 q
Signature
2.2 Authorized Agent:
Levi.s -T- G ,Ne A fI s 9 4 NAY
Name(Print) Current Mailing Address: C
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit aoolicant
1. Building (a)Building PemlifFee
�/7 �t�. oc
2. Electrical (b)Estimated Total Cost of
N 4 Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) "V14
5. Fire Protection
6. Total=(1 +2+3+4+5) -7 K �'ta Check Number 3
�} -This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature: -
Building CammissionerAspeto`r diBuuaings - Date
20 PENCASAL DR BP-2009-0502
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block: 29-285 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0502
Project# JS-2009-000693
Est. Cost: $4700.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. (lass_ Contractor: License:
Use Group LOUIS J GINGRAS 133999
Lot Size(sq. ft.): 27791.28 Owner: POULIN THOMAS A&PATRICIA J
zouina: URA(100)/[WSP Applicant: LOUD J GINGRAS
Applicant Address: Phone: Insurance:
244 HAYDENVILLE RD (413) 586-7420
LEEDSMA01053 ISSUED ON:1111012008 0:00:00
TO PERFORM THE FOLLOWING WORA:REROOF & SIDE SHED
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:
Finai: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:OK q- ® 9-14n
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULAT NS.
Certificate of Occupancy Signature:
FeeType: Date Paid: _ Amount:
Building 11/10/2008 0:00:00 $35.001.539
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo