23A-161 (3) r
k
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 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.
Tate
Address of work
location
r
J
The Commonwealth of Massachusetts
Department of Industrial.4ccidents
Office of Investigations
600 IEashington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/In divi dual).' �� r
-6 i
Address:
City/State/Zip: / Phone#:
Are you an employer?C—iFeck the appropriate boa: Type of project(req' fired):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
have hired the sub-contractors 6. ❑New construction
em es(full and/or part-time).* `
2 am a sole proprietor or partner- listed on the attached sheet. 7. U Remodeling
These sub-contractors have
ship and have no employees 8. ❑Demolition
working for me in any capacity. Unlployet_s a,td have H1u1kc1's'
[No workers' comp. insurance comp. insurance.*
9. Building addition
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
officers have exercised their
3.❑ I am a homeowner doing all work 1 - Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.F-1 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' la•❑ Other
comp.insurance required.]
*Any applicant that checks box 111 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.
'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 thepolicy and jab 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 we11 as civil penalties in the form of a STOP WORK ORDER and a fine
of i ip to,$250 00 a clay against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi nder the pains and ties of perjury at the information provided above is true and correct..
Sianature: A Date:
Phone#: '
nfficirrl rrse nrtll. Do not write in this area,to be completed by ciol or town uncial
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Flealth 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 Su ervisor: Not Applicable ❑
Name of License Holder
License Number
� � L
AddresA Expira ion Date
Sig e Telephone
7 C
ister Home Im rovement:Cotitractor. Not Applicable ❑
Coma N Regissttraftio"n� Numbed,
Address Expiration Date
1 Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G'.L.c.152,§25C(8))
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...... ❑
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 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-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)ofthe Massachusetts General Laws Annotated,you maybe l a�lrlia lr rut I,eisuu(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Buildin Code.City of
- -
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0) Other[p]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes 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`ekisting housing','Comptete the following:
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
as Owner of the subject
property
hereby authorize
to ac iy behalf, in all _ relative to work aut or ed by this building permit application.
Sign ture of Owner Date
as Owner/Authorized
Agent her die are that the statements an information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains andpr ies of perjury.
e J �
Print Name
i na Owner/Agent Date
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
Side L: R L m__m..' R _.._
Rear
Building Height
Bldg. Square Footage __._
Open Space Footage °
/o
(Lot area minus bldg&paved
parking)
#of Parking Spaces - •. „-~
Fill:
f
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES
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#'
S. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
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 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
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 7 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
D C Mart " Lse !11� y
City Of Northampton
�� ry Building Department Curb C�ttlDr�veway Permi#
212 Main Street Sewer/Septic varlab�Ti#y
d
Room 100 1Na#er/tNefl�#vallabllity
Northampton, MA 01060 Two Sets of StructuraiPlans '-
phone 413-587-1240 Fax 413-587-1272 PIot,Sfte Plans s
e
Qther. .Perafy.
5 ,x
PLICATION TO CONSTRUCT,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
y Zone
I Overlay
District
Et m St
GB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner ecord: ' / � ✓
Na/me(Pri t) Current Mailing Address:
Telephone
Signature^�
2.2 Authorized Agent:
Name(Pr Current Mailing Address:
Sig r Telephone
SE ON 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
coApleted by ermit applicant
1. Building \ (a)Building Permit Fee
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) Cheek Number a'
This Section For Official Use Onl
Date
Ruiiriing Permit Number: issued.
Signature:
Building Commissionedinspector of Buildings Date
68 PINE ST BP-2015-0608
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A- 161 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2015-0608
Project# JS-2015-001176
Est. Cost: $2400.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES ROBERTS 99404
Lot Size(sq. ft.): 14026.32 Owner: WAKIN ELEANOR
Zoning:URB000)/ Applicant: JAMES ROBERTS
AT. 68 PINE ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON:121212014 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE FRONT 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 12/2/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner