10-015 BP-2011-0253
GIs #: COMMONWEALTH OF MASSACHUSETTS
A M M, -' �1 _.: 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- 2011 -0253
Project # JS- 2011- 000423
Est. Cost: $16000.00
Fee: $151.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK ALBRIGHT 079655
Lot Size(sq. ft.): 91911.60 Owner: ALBRIGHT MARK D
Zoning: RR(100) //WSP Applicant: MARK ALBRIGHT
AT. 481 KENNEDY RD
Applicant Address: Phone: Insurance:
141 WATER ST (413) 259 -5015 (�
LEEDSMA01053 ISSUED ON :912712010 0:00:00
TO PERFORM THE FOLLOWING WORK.- REMODEL KITCHEN & REROOF,10 /26/10 -
AMENDED T',q10#0ML SATHkCOM & NEW KITCH WINDOW
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 Si
FeeType: Date Paid: Amount:
Building 9/27/2010 0:00:00 $151.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP -2011 -0253
APPLICANT /CONTACT PERSON MARK ALBRIGHT
ADDRESS/PHONE 141 WATER ST LEEDS (413) 259 -5015 Q
PROPERTY LOCATION 481 KENNEDY RD
MAP 10 PARCEL 015 001 ZONE RR(100)/IWSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REMODEL KITCHEN & REROOP T O M.
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 079655
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFPRMATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
(0/1( Io
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
City of Northampton
Building Department
.212 Main Street � K
Room 100
'Norttfpmpton, MA 01060
phone 413 -1240 Fax 413 - 587 -1272
x
tt.. '.
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
q g 1 ��� R Map Lot Unit
LJ S �� �� 3 Zone, Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner /�. of Record: I �y� 1 , _f M ,p ,t
Mor ��) ►i /ma I b�jgr4 �`�/ WwIQ.,r s Lt J5 I"�1 0/o.�3
Name (P ' Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTIOK COSTS
Item Estimated Cost (Dollars) to be Official Use Only
com leted by ermit applicant
1. Building �s00 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
3� Construction from 6
3. Plumbing 2500 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Totaf = (1 + 2 + 3 + 4 + 5) .S 3 Check Number
This Section For Official Use Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
w
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 `� � 1
Frontage L
Setbacks Front 7
Side L: R: L: ` R: 20
Rear = 2 O
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg & paved 2 90 I
p arkin g)
# of Parking Spaces I— — — --
Fill: I
volume & Location 1 I
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:! j
IF YES: Was the permit recorded at the Registry 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 DONT KNOW Q 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:
z
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, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
a
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all aaplicablel
New House ❑ Addition ❑ Replacement�windows Alterations) Roofing El
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [G7 Siding [O] Other [O]
Brief Description of ,,,, led �.� 1 Q� 1 I �I f � � � q �1
� S , nfr� � rq a re Mock g rooms (,-
Work: n � �
Alteration of existing bedroom Yes �_ No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa lf.Nevr.house am ° r a difi r>t tc>,.'ezist� c�-= hor�srnp .cei»aFi�t :tFtr fiaiSi wiri<a:
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.
1. 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
I iA A ir- �f ,as Owner /Authorized
Agent hereby declare that th# 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.
a f^ � D. A/&-,
Print Namea� oL.t
162 /v
Signature of Owner /Agent Date
SECTION 8 - CONSTRUCTION'' SERVICES
8.1 Licensed Construction Superv l Not Ap 0
Name of License Holder �Qrk IJr / ` 6 " "
License Number
lyl c 6 s - -3 /a/23 ZZ())
Address ` - Expira n Date
#13 2 T -S01,
Signature Telephone
B. Rec inter d tome,l m rov ment dontractar:� ,,..._..,b, ., '? . ._ .:.,.. .., r Not Applicable ❑
M 11, /S / 202
Company Name Registration Number
23 - 2 0 1 - 2,
Address Expira ion D to
Telephone
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.
Signed Affidavit Attached Yes....... ❑ No...... ❑
.. = �•
1.1 i j m nerd iem U0
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 -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) 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
The Commonwealth of Massachusetts
Department of Industrial Accidents .
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov /dia
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information L / Please Print Le 'bIv
Name ( Business /Orgmization/Individual): F A brl
Address: 141 W axis . IqA
City /state/Zip: Lctj-s M oros - j Phone. #: A/3) 25
Are you an employer? Check the appropriate'box: Type of project (required):.
1. ❑ I am a employer with . 4._ El I am a general contractor and I
employees (full and/or part- time).
* have hired the sub- contractors 6. 11 New construction
2. Q I am sole proprietor or partner- listed on the attached sheet. 7. Remode �
ship and. Have no employees These sub - contractors have. .8. 0 DemoMon
working for me m any capacity. enTjoyees;and Kaye workers'
� 4 Boil ad n
ditio
[NO `v wOrkeTS' COmp. insuranc _ cornp, incttrant-.P ! '. .- Q _
required:) 5. We are a corporation and officers have Lercised their its 10.0 Electrical repairs or additions
3. I am a homeowner doing all work .; 11.❑ Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12. Roof repairs
c. 152, ,
insuran required.] ? § 1 4 and we have no ()
employees. [No workers' 13.0 Other
COUP. insuranc wed-].
`Any applicant 4hat checks box #.I Est 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.
IConuactors that check this box must.attached an additional sheet showing the name of the sub - contractors and state whether or not thosrattities have
employ -- 'If the sub - contractors bane employees, they must provide dish worixrs' comp. policy number.
lam an employer that is. providing workers' compensation insurance for my employees Below is the policy and job site
information
Instn-ance Company Name:
Policy # or Self-ins. Lic. #: Expiration Date:
Jo S ite Addre City /StatelZip:
Attach a copy of the workers' - compensation policy declaration puge'(showing the p9licy number and ez pration date).
Failure to secure coverage:as required under Secti on 25A'of1VlGL`C. TSZ sari Iead to the miposi on of criminal peaaIties of a
fine up to $1 500.00 and/or one -year imprisonment; as well as civil penalties is 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
<. _.:.:._ _ �. _
__......
I`nvestieation's ofthc CIA for
_I do hereby certify th
er jury that - the information provi&d- rbove_issrue_aadrvnec --
Signature: ate 0
Phone #: (0 3) 23 -
Official use only. Do not write in this area, to be completed by crty or town offu taI
City or Town: Permit/License #
Issuing Authority (circle one):
J. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PlumbEInspect]or
6. Other
Contact Person: Phone #-
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 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
Date
Address of work
location
W�njO j FrQ M) f) ` I
11
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481 KENNEDY RD -' BP- 2011 -0253
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map :Bloc 10 - 015 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- 2011 -0253
Project# JS- 2011 - 000423
Est. Cost: $16000.00
Fee: $96.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK ALBRIGHT 079655
Lot Size(sq. ft.): 91911.60 Owner: ALBRIGHT MARK D
Zoning: RR(100 )//WSP Applicant: MARK ALBRIGHT
AT. 481 KENNEDY RD
Applicant Address: Phone: Insurance:
141 WATER ST (413) 259 -5015 Q
LEEDSMA01053 ISSUED ON :912712010 0:00:00
TO PERFORM THE FOLLOWING WORK.- REMODEL KITCHEN & REROOF
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 9/27/2010 0:00:00 $96.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
VNfAi = r—AU CTs + fkXT((r4S,
File # BP- 2011 -0253
j� �iE c►�- �4��tE r f��
APPLICANT /CONTACT PERSON MARK ALBRIGHT
ADDRESS/PHONE 141 WATER ST LEEDS (413) 259 -5015 Q
PROPERTY LOCATION 481 KENNEDY RD
MAP 10 PARCEL 015 001 ZONE RR(100 /) /WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction:_ REMODEL KITCHEN & REROOF
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 079655
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFPRMATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
9 z; 10
Signature of Buildint Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
r
City of Northampton x
Building Department �
212 Main Street y
1 2 ,Room 100 xv
S�� 2
Nbrtham, pton, MA 01060
phone 41'3- 5$1240 Fax 413 - 587 -1272 a�
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
o% Map Lot.
� Zone Oyerlay"District
Ew St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) ` Current Mailing Address: Q X53
v' k �' s , I1 � t
Telephone /1 2 3 .0 j
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
com leted by ermit applicant
1. Building 1 O 0 o (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) 4I 00 Check Number
This Section For Official Use Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /inspector of Buildings 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 „t - ___.- s`�_^ -� j ,
Frontage 15
Setbacks Front 1S i j saw
Side L: I R L: ` R: I {
Rear ---
Building Height r ---- -- '
Bldg. Square Footage [�' - -- %
Open Space Footage % _
(Lot area minus bldg & paved
p arkin g)
# of Parking Spaces --
Fill:
volume & Location)`
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW YES 0
IF YES, date issue&
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
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
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 0 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 1 acre? YES 0 NO / 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding [O] Other[' Q
Brief Description of Proposed
Work: g o, vC H\ \4n M Mo �f-
Alteration of existing bedroom Yes 1� No Adding new bedroom Yes — No
Attached Narrative Renovating unfinished basement — Yes No
Plans Attached Roll - Sheet
6a Iftevu �iisndir:atlii�vi toextltxatosi at�e.2he�oitcri:
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 act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
A 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.
p v.r
Print Name
Signature of Own r /Agent Date
4
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑ c
Name of License Holder MQ f I_ C-5
License Number
y I VJe�Ac_r 01 OS 0 13 I
Address Expirati n Date
( H(3)
Signature Telephone
S 12risteredkornrYirriettient £:(itratfur s : a.,� ..mom': Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152 § 25CM)
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....... A No...... ❑
F
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 hom eowner.
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 buildine 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
s r
The Commonwealth of Massachusetts
Department of Industrial Accidents .
Office of Investigations
600 Washington Street
U Boston, MA 02111
www mass gov /dr'a
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plambers
Applicant Information ( Please Print Lee
Name ( Business /Organim ion/Individual):. a►r' f'►a 1n
Address:
City /Sta&Zip: L¢.J s MA - Phone. #:
Are you an employer ?.Check the appropriate'box: Type of project (required):, /�
1. E3 am a employer with 4.. E] I am a general contractor and I 6. [1 New construction
employees (fall 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 have no, loyees These sub - contactors have .8. Demolition
working for mein airy capacity. SIP- Yees__aad have workers' -0 Bu T� a0I1
[No workers COMP lnSInsurance
- CQI!]p. mci�ranr,• LJ_
required] 5. Ej We are a corporation and its 10.[ Electrical repairs or additions
3.$ I am a homeowner do' all work officers havexercised their 11. Plumb' mg ❑ mg repairs or additions
myself [No workers' comp. right of exemption per MGL
have no 12. Roof airs
insurance required] ?
c: 152 ' § 1(4), and we -
- �
employees. [No workers' 13 Other
comp. insurance required].
'Any appiicant that checks box Al rm also fin out the section below showing theirworkers'- compensation policy information.
t Homeowners who submit this affidavit.mdicatiing they are doing an work and then biro outside cont wt= must submit a new affidavit indicating such:
rCormactors 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 tub - 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 rind job site
information.
Insurance Company Name:
Policy # or Self- -ins. Lic. #: Expiration Date:
Job Site Address: City /Sta&Ztp
Attach a copy of the workers' - compensation policy declaration page'(showing the pglicy number and ezPiration date).
Failure, to secure coverage: as re qun imder.SedT 25A ofIG MG &.. 152 caii lead the imposition of ciimmalI 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 tiie violator. Be advised that a
copy of this statement maybe forwarded to the Office of
_ - .. �. -.
I do hereby certify the p`C J and p erlury that the rnformatlon provided a e_ aadcarrect__:__
Signature:
- ate 7 Z/ ��
Phone #:
Official use only. Do not write in this area, to be completed by city or-to wn offkw
City or Town: Permit/License #
Issuing Authority (circle one):
J. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #•
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 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 insRections 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
�ermits 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, f Y' C'Z L understand the above.
.(Home owner /reside 's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date R/ �®
Address of work ,
location