35-108 (2)INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as l:is /her construction sups: :i Sor. 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 rouzh 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, Ic Cc A „� ti�,C U.- 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 — i6 — a
Address of work
location c /414 I e- C i4 wF —rE�Q .
T e 6I?ErlC6- 0 A14 . O(OKA
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of In vestigations
0 600 Washington Street
Boston, MA 02111
°'^ s www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information g
/� Please Print Leibly
Name (Business /Organization/Individual): Gew �4 L D i n1 e- -"E M PG Efia rV
Address: 4� (� A H 1 L CA We_- .
City /State /Zip: FLOOR E CAI C. E MA , Phone #: cf 13 S 0":"'C/ - o? 0,53
Are you an employer? Check the appropriate bog:
1.0 I am a employer with
4. F� I am a general contractor and I
employees (full and/or part- time).*
have hired the sub - contractors
2.0 I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub - contractors have
working for me in any capacity.
employees and have workers'
o workers' comp. insurance
comp. insurance.$
equired.)
5. 0 We are a corporation and its
3- VI am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
comp. Insurance
Type of project (required):
6. 0 N construction
7. Remodeling
8. 7 Demolition
9. 0 Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.0 Roof repairs
13.0 Other
*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.
xContractors 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. #:
Job Site Address:
Expiration Date:
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
Investieations of the DIA for insurance coverage verification.
I do hereby certi under the pains and penalties of pe�rjury –that the information provided above is true and correct
Si ature: - Date: 6
Phone #: ct / 3 — _ S `j 3
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, ERVICES
8.1 Licensed Construction Supervisor:
Name of License Holder
Not Applicable
License Number
Address
Expiration Date
Signature Telephone
9 Reaisteied Homehfil rovemeritCont r racto r W, , -,,
Not Applicable
Company Name
Registration Number
Address
Telephone
Expiration Date
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.
Affidavit Attached Yes....... ❑ No...... ❑
11.. Hom6e 0 net�Eiemption
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
+I
SECTION 5- DESCRIPTION OF PROPOSED WORK (check.all applicable)
New House ❑
Addition ❑
Replacement Wfdows Alteration(s) � Roofing
Or D L
Accessory Bldg. ❑
Demolition ❑
New Signs [ED] Decks Siding [pj Other [C31
Brief Description of Proposed
&F_ St f A N (r GLA55
Work: .(70 6
Alteration of existing bedroom Yes No Adding new bedroom Yes �� No
Attached Narrative Renovating unfinished basement Yes ZNo —
_
Plans Attached Roll - Sheet
sa If New douse and oraddition °to existing housing: complete the f6 IdWinm
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 No. Is construction within 100 yr. floodplain 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
1, , 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
Signature of Owner /Agent Date
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
Side
Rear
_
L v__— R:.._- ...._..?
L.� R ,..._...- ,
Building Height
Bldg. Square Footage
%
Open Space Footage
(Lot area minus bldg & paved
parking)
%
_
_ —
# of Parking Spaces
Fill:
(volume & Location)
Section
A. Has a Special Perm it /Variance /Findin ver been issued for /on the site?
NO DON'T KNOW Q YES
IF YES, date issued:..
IF YES: Was the permit recorded at the Re ' try of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page! and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW () YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES 0 NO
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
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, ex vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
X11 y�_
y
2.2 Authorized Agent:
Name (Print)
Signature
SECTION 3 - ESTIMATED CONSTRUCTION-COSTS-
Item Estimated Cost (Dollars) to be
comoleted by Dermit applicant
Current Mailing Address:
Official Use Only
1. Building I 3 q - o 6 0 I (a) Building Permit Fee I
2. Electrical
3. Plumbing
Total Cost of
Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 32,5-61. 60 Check Number
This Section For Official Use Only
Building Permit Number._
Signature:
Date
Issued:
Building Commissioner /Inspector of Buildings Date
Clty of Northampton
,- Building Department
SECTION 1 - SITE INFORMATION
212 Main Street
SeuueSe tialil ,
Room 100
MAAva tiaE[
n
- Northampton, MA 01060
wa Sesf Structural Pt r .. ,
413
7,
�hdi91��413 -587 -1240 Fax -587 -1272
Pr4t�S�te Ptans
�, "a� � �
Of�erSpecrfy
-
APPLICATI0N7f'6-,COI4s -f UCT, ALTER, REPAIR, RENUVA I h UR uEMOLISH A ONE OR TWO FAMILY DWELLING
2.2 Authorized Agent:
Name (Print)
Signature
SECTION 3 - ESTIMATED CONSTRUCTION-COSTS-
Item Estimated Cost (Dollars) to be
comoleted by Dermit applicant
Current Mailing Address:
Official Use Only
1. Building I 3 q - o 6 0 I (a) Building Permit Fee I
2. Electrical
3. Plumbing
Total Cost of
Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 32,5-61. 60 Check Number
This Section For Official Use Only
Building Permit Number._
Signature:
Date
Issued:
Building Commissioner /Inspector of Buildings Date
SECTION 1 - SITE INFORMATION
This section to be completed by office -
1.1 Property Address:
oC ca C/q 14 14.LpgiV Tile
7,
"Lot Unit
L D IQ E w C �
/r1
Zone Overlay Drstnct
-
Elie 5t. District
. CB Drstnct
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZEDAGENT
2.1 Owner of Record:
6!6-kA 4131 ryJC
Frto �/
a 6
Cf'► +� �L c-bq ry� �E iQ .
Nam (Print)
I l(ti I� %\� �-�-
/ ��
w, _
Current Mailing �d� ss:
7
Telephone
2.2 Authorized Agent:
Name (Print)
Signature
SECTION 3 - ESTIMATED CONSTRUCTION-COSTS-
Item Estimated Cost (Dollars) to be
comoleted by Dermit applicant
Current Mailing Address:
Official Use Only
1. Building I 3 q - o 6 0 I (a) Building Permit Fee I
2. Electrical
3. Plumbing
Total Cost of
Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 32,5-61. 60 Check Number
This Section For Official Use Only
Building Permit Number._
Signature:
Date
Issued:
Building Commissioner /Inspector of Buildings Date
Category:
w
BP- 2007 -1127
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Permit # BP- 2007 -1127
Project # JS- 2007 - 001800
Est. Cost: $3950.00
Fee: $50.00
Const. Class:
Use Group:
BUILDING PERMIT
PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
Homeowner as Contractor
Lot Size(sq. ft.): 9931.68 Owner: TEMPLETON GERALDINE
Zoning: SR Applicant: TEMPLETON GERALDINE
AT. 26 CAHILLANE TERR
Applicant Address: Phone: Insurance:
P O BOX 60123 (413) 586 -2043 O
FLORENCEMA01062 -0123 ISSUED ON :511712007 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE SLIDING DOOR
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W.
Underground: Service: Meter:
Rough: Rough: House #
Driveway Final:
Final: Final:
Gas: Fire Department
Rough: Oil:
Final: Smoke:
Building Inspector
Footings:
Foundation:
Rough Frame:
Fireplace /Chimney:
Insulation:
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 5/17/2007 0:00:00 $50.009348
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo