35-206 HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 7800 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/footing's (before backfill).
sonotube holes (before pour) a roueh 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 insaected.
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 thy as the proper permits and inspections are
made
T t� 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 7-- L'— O LT
Address of work
location Ja Sll/ C30/'-A /"AorL d
Ro/'?Ac- -I .44 0 l 0 6 i2
The Coinmonweaith of Alassachzrserrs
Deparnmenr Of 1f2dUSt,- a!ACCiJ_-7ZrS
0 T.Ce 0f r,vesni anions
_ 600 if ashin�ron S7 weer
Boston, L-4 02111
mass.;0v1dia
'Workers' Compensation Insurance Aflidayit: Builders/Contractors/Electricians;Piar:bers
Analicant Information Please Print Legibly
'��e (B usiness�Or�ani:ariorulndividua?�: � .� / ' ✓1
Phone r: 413'— 7 7 _ 30 3�
Are you an employer' Check the appropriate box: Type of project(required):
4. I am a general contractor and I
i.❑ 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. ❑ 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. [-\o workers' comp. right of exemption per MGL 12.7 Roof repairs
insurance required.]' c. 152, §1(4),and we have no
employees. [No workers' 13„ 1 Other 1.Jd S�We.
comp. insurance required.]
"Any applicant that checks box=1 must also 5.11 out the section below showing their workers'compensation policy information.
a
Homeowners who submit this ffidavit indicating they are doing all work and then him outside contractors trout submit anew 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.
lam an employer that is providing work ers'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 sec ure coverage as required under Section 25 A of 1�iGL c. i=2 can lead to the,-.rnposinon of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonment, as well as civil penalties in the forsi of a STOP WORK ORDER and a fine
of up io 5250.00 a day against the violator. Be advised that a copy of this statement Tray be forwarded to the Office of
Investigations of the DLz for insurance coverage verification.
I do hereby certi under the p sand penalties ofperju -that the in�ormarion provided above is true and correct.
Si?nature: � Dale: LTC
Phone:`:
J jiXial use 017111*. Do not write in this area, to be completed by city or town of ciaL
City or Town: Permit;Zicense
Issuing Authority (circle one):
1.Beard of Health 2.Buildina Department 3. City/Town Cleric 4.electrical Inspector 5.Plumbing Inspector
6. Other
i
Phone
Contact Person: T: j
SECTION E -CONSTRUCTION SERVICES
E.1 Licensed Construction Supervisor: /VJA i No Applicable ❑
Name of License Holder
License Number
'caress Expiration Date
signature Telephone
K.Reuistered Home lrnQrvvem"ent CQntiadtor l Not Applicable ❑
:omoanv Name Registration Number
cress Expiration Date
Telephone
ECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G.L.c.432,§25C{6))
�crkers 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 Dwellines of one(1) or two(2)families
and to allow such homeowner to enuage an individual for hire who does not possess a license, provided that the owner acts
as supervisor.CNIR 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 subrut to the Building Otncial,on a form acceptable to the Building Official.that he/she shall be
responsible for all such work performed under the building permit.
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 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated, you may be Iiable for person(s)
you hire to perform work for you under this permit.
The undersized"homeowner"cc--tines and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local _Laws and State of Massachusetts General Laws Annotated.
Homeowner Si-nature
. I SECTION 5- DESCRIPTION OF PROPOSED WORK(check all aDoHcable)
I New House Addition Replacement Windows Alteration(s) Roofing
r-1 Or Doors
Accessory Bldg. a Demolition New Signs [p] Decks [Q Siding(pi Other�w
Erief Description of PrP P ( f
V'✓c rk: `�.}+tu VT ovrL �ylb ii1 =S �`�L
'iteration of existine bedroom Yes)_No / Addine new bedroom Yes _No
A-,ached Narrative Renovatina unfinished basement Yes >e No
Plans Attached Roll -Sheet
6a.If New house and ar addr`TH ori to existina housina.complete the foilawina:
a. Use of building: Ore Family Two Family Other /y `
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
c. 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-ZE COMPLETEIT=WFfEN
OWNERS—AGENT ORCONTR:4C€OR"APPLIES POR_i3U1tIItNCPEkMIT
as Owner of the subject
prcPerty
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
I
Signature of Owner Date
as Owner/Authorized
.gent hereby declare that the sta*:emems and information on the foregoing application are true and accurate, to the best cf my knowiedae
and belief.
Sig-ed under the pains and penalties of penury. I
Fnnt Blame
I
cn2t_r_ct w ' cent
I
Section 4. 71NING i All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zonina
This column to be flled in by
Building Depamnent
Lot Size ....._a..
i
Frontage
Setbacks Front
Side L: R:99...,I L
___.. R
Rear
Building Height
Bldg. Square Footage .'] ...... % _ .. _....
Space Footage %Lot ea minus bldg&paved[,(O-pen
arldne)
i#of Parkine Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW (g YES 0
IF YES, date issued:`,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 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:r
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO C
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
IF YES,then a Ncrth ipton Storm Wffer ManagemernfPeimitfrom the DPW is required.
Department use only
City of Northampton Ski otkm1i.,
Building Department , u ay.Permit
212 Main StreetvVerlSe}it[ aiiability
Room 100 ' Water efI-A ability
Northampton, Mr. 0106 r w of Struct I Plans
phone 413-587-1240 Fax 413-5$7-1272�U� atlslfe Pla
Otir
APP L]CATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE,QR bEMOLISH'A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 ProDerty Address:
:
U:4q 'T05 PA Ro tl pray Lot Unit
zone Overlay District
flvf zncz, h A 0 to4e,,
Elhi St District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
p.}
Name(Print) Current Mailing Address:
yl'�-77�- X03
s ¢ Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit aoolicant -
1. Building (a)Budding Permit.Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing i Building Permit Fee
4. Mechanical(HVAC)w°O 5 r'- ac
5. Fir= Protection /g f, "o
6. Total= (1 +2+3+4+5) I "; Check'Number
This Section For Oficiat'Use Only
- Date
Building Permit Number Issued:
Signature:
Building,.Commissioner/Inspector o 90uomgs- '""" Date
BP-2009-0026
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-2009-0026
Project# JS-2009-000037
Est. Cost: $700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 67082.40 Owner: HOFFMAN STEVEN&BONNIE
Zoning: SR Applicant: HOFFMAN STEVEN & BONNIE
AT. 1244 BURTS PIT RD
Applicant Address: Phone: Insurance:
1244 BURTS PIT RD (413) 774-3036 0
FLORENCEMA01062 ISSUED ON:71812008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WOODSTOVE
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 7/8/2008 0:00:00 $25.001019
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
1244 BURTS PIT RD
B P-2009-0026
GIS COMMONWEALTH OF MASSACHUSETTS
Ma ::Block: 35 -206 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-2009-0026
Proiect# JS-2009-000037
Est. Cost: $700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg. ft.): 67082.40 Owner: HOFFMAN STEVEN&BONNIE
Zoning: SR Applicant. HOFFMAN STEVEN & BONNIE
AT "1244 BURTS PIT RD
Applicant Address: Phone: Insurance:
1244 BURTS PIT RD (413) 774-3036
FLORENCEMA01062 ISSUED ON.71812008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WOODSTOVE
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: 3•��
THIS PERMIT MAY BE REVOKED BY TH ITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIO
e � J
Certificate of Occu anc Signature:
FeeType: Date Paid: Amount•
Building 7/8/2008 0:00:00 $25.001019"
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo