38D-049 HOMEOWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CIMR 108.1.4 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 stakes, which include foundation/footings (before backfill).
sonotube holes (before pour) a rough building inspection (before work is
concealed). insulation insaection (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 occupanev
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
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tii orkers' COMDensation Insurance -Affidavit: Builders;'Contractors;' -Iectricians;Tli-lmbers
A oDlicant infor-oration PIease Print Leaibly
�'2`I7z (Business/Oraaniza " n/tic, ).
Address: C jv&. 41
Citv;StateiZip: 4 06 Phone r: /` �/ '
Are you an employer?Check&appropriate box: Type of project(required):
1.❑ I arm a employer with 4" ❑ I am a general contractor and I
ployees (full and/or par-time).* have hired the sub-contractors
6. _New construction
2 I am a sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling
ship and have no employees These sub-contractors have g" ❑Demolition
working for me in an capacity. employees and have workers'
Y F tY" 9. ❑Building addition
[N-o workers comp, insurance comp. insurance.:
required"] 5. ❑ W e are.a corporation and its 10.7 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I I"❑Plumbing repairs or additions
myself. [moo workers' comp. right of exemption per VIGL 12 oofrepairs
insurance required.] t c. 152, §1(=1),and we have no 13.7 Other
employees. [- o workers'
comp.insurance required.]
any applicant that checks box=l must also fill out the section below showing their workers'compensation policy information.
Homecwne s 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 ar.ached an additional sheet showins the narne of the sub-contractors and state whether or not those entities have
employes. 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
inform ation.
Insurance Company Name-
Policv 1 or Self-ins.Lic.1-: 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_N/IGL c. 152 can lead to the imposition of criminal penalties of a
fne up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORD 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
Invesn'zaaors of the DLa for insurance coverage verification.
I do hereby eer ' under the iN and penalties ofperjury that the information provided above is trice and correct-
Date:
Phone= 11 r
Official use only. Do not wrire in this area, to be completed by city or town ojficiaL
Citir or Town: Permit7-icense
Issuing Authority (circle one):
1.Bcard of Health 2.Building Department 3. City/Town Clerk 11.Electrical Inspector 5. Plumbing Inspector
6. Lather i
t - i
Contact Person: Phorne T: I
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Suoerrsor: Not Applicable ❑
Name of License Holder
License Number
�adress Expiration Date
K--1
Sig ure Telephone
I
t.R'ea ste d Home Improvement`Cobtractor Not Applicable 13
:omo nv Namd Registration Number
i
ddress Expiration Date
Telephone
ECTION 1:0-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 132,§25C(fs})
lorkers 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 buiidine
=it..
aned Affidavit Attached Yes....... - No...... ❑
f1' . Home'Qerg+aniia
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. SLith 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 OEcial,on a form acceptable to the Building Official.that helshe shall be
responsible for all such work performed under the building hermit
As actins 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 ofEmployers to
Employees for injuries not resulting in Death)of the lvlassachuserts General Laws Annotated,you may be Iiable 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
SECT ION DESCRIPTION OF PROPOSED WORK(check all armlicabie)
New House i Addition Replacement Windows Alterations) Roofing
Or Doors r7
Accessory Bldg. ❑ Demolition New Signs [!✓] Decks [F7 Siding [177", Other jQ]
Brief Description of Proposed ii �, c
Work: R T1r �; I �'1 S \'V"1�1w�� l� '. _),
s
Alteration of existing bedroom Yes No Addinc new bedroom Yes No
Attached Narrative Renovatina unfinished basement Yes No
Plans Attached Roll -Sheet
6a.'if Ne:w Eiouse'an' araddrt1oi to existtng'hoclsina.comofete tl1 folfoinrin :
a. Use of building: One Family Two Family Other
b. Number cf 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 Woedstoves 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 corfcrm to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION TCF.BE COMPLETED--WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILD; 1NGPE1
as Owner of the subject
prcperry
hereby authorize
to act on my behalf, in ail matters elative to work authorized by this building permit application.
Signature of Gwn r Date
1 j E - --• as Owner/Authorized
Agent hereby deciar that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Sicred under the pairs and penalties of penury.
Fnnt Narne
' I
S�cnabure cf��wrer nt a,<
'
'
~
SectJor, 4. ZONING ALL Informalion Must Be Compteted. Permit Can Be Denied Due To Incomptete Information
Existma Proposed Requ,red by Zoning
This cohimn to be filled in by
Building Department
Lot Size
Setbacks Front
Re
Building Height
FOPen Space Footage %
a minus bldg&paved
Lo
OL
ta
ofParkina Spaces
(volume&Location)
A. Has a Special Permit/Vahance/Finding ever been issued for/on the site?
�_�
� v~� �~�
NO \~�-� DON7KNO�/ YES �_�
IF YES, dateissued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO �° KNOW) DONT KN� YES
IF YES:� enter Book Page' | and/or Document#/ '
B. Does the site contain a brook, body uf water orwetlands? NO 0 DDNTKNOYY 0 YES 0
IF YES, has permit been or need to be obtained from the Conservation Commission? '
Needs to be obtained �~\ Obtained v—� Date^�� . �~/ '
C. Do any signs exist on the property? YES v~� 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 0
IF YES, describe size, type and location: '
E. Will the construction activity disturb(clearing,grading adon, or filling)over acre oris it part ofa common plan
that will disturb over Iacre? YES � ) NO K )
�� v�
IF YES, then allortF-i—mcit-oh85�m-Mlt-e—r Man-agemdnfpernit from the DPW isrequired.
y 'Departrnent use only
�I r City of Northampton Status of Permit
Muilding Department Curb Cut/D 6way Permit
' 212 Main Street SewerfSepti6Availability
Room 100 F/tlatecfUVelfAvailability �
1 Northampton, MA 01060 Two Seta of StructuraFPlans
phone 413-$87-1'40 Fax 413-567-1272 Plot(Site Plans
Other Spe-
APPLICATION 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
Znne Overlay District
Elrri'St.District CIS District
SECTION 2-PROPERTY OWNERS HIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) - �— Current Ma-fin!Address,-.,�� r
Telephone
Signature
2.2 Authorized Agent:
i L. lei L a,) 'l
Name(Pant) _ Current Mailing Address
Signature J Telephone
SECTION 3-'ESTIMATED CONSTRUCTION COSTS'
Item I Estimated Cost(Dollars)to be Official Use Only
completed by permit apolicant
1. Building (a)50ding'Permit Fee
2. Electrical (b) Estimated Total:Cost 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 0nl
Date
Building Permit Number. Issued:
Signature:
Building,commis rA
sonenspector_o ui omgs Date
BP-2009-0953
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-2009-0953
Project# JS-2009-001379
Est.Cost: $9600.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY J LUCE 149288
Lot Size(sq. £t.): 5401.44 Owner: VOLLINGER MARY N
Zoning: (100)/ Applicant. TIMOTHY J LUCE
AT. 33 WINTHROP ST
Applicant Address: Phone: Insurance:
P O BOX 14 (413) 387-9800
LEEDSMA01053 ISSUED ON.511412009 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 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 5/14/2009 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo