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1
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 rewires that the building dep artment 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
--------------- pennitt.- i-n- conjunctionto_the_building ermit issued,_ 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.
Address of work
location
The Commonwealth of Massachusetts
Department of Industrial Accidents
T E i • Office of Investigations
=°fit= e 600 Washington Street
1 _ s'
Boston, MA 02111
� www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information y Please Print Legibly
Name (Business/Organization/Individual): . \ A , r ICS e' /1
Address: {' Ci c,s( ck, , 5,-
City /State /Zip: gcrin- Ar- 3 /44 Oil) 2 Phone.#: A/LE - C 4 " 7 6
Are you an employer? Check the appropriate box: Type of project (required): i
1.0 I am a employer with 4.. 0 I am a general contractor and I
6. 0 New construction
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 7- Remodeling
ship and have. no Ioyees These sub - contractors have g 0 ego; on
working for me in any act employees and have workers'
y c aP ty 9 0_Butlding addition
[No- workers' comp. insurance come insurance
required.] 5 We are a corporation and its 10.0 Electrical repairs or additions
o e shave xercised their _- 1. plumbin repairs or additions
3.0 I am- ahsmeowner- detng�ll- work ❑ O n g -eparrs
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*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.
tContractors 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. #: ' 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 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. e advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certify under the pains and penalties ofperjury that the information provided above is.true_atrd correct -
Si • , .tore: .� �•- l - -- _
bate- ' 0
P hone #: 4 ) 1 K t- --, - 9 ` - ,E-- - /
Official use only. Do not ; tobe comp by city or town officiaL
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 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 Supervisor: n Not Applicable ❑
Name of License Holder : '-Sat `\, +1 / 1 A a ( 9
License Number
Address Expiration Date
6 t.nvtot r.c- ,dam G t7 -5-- 7
Signature Telephone
77 s - - 3 26
S.. Re ® is.tered °'.. e..irt r.r;
.�_�" � aac for^ - .y....._.. ....�.. � ..�.. � v, Not Applicable ❑
Company Name Registration Number
Address ` Expiration D
S2. ��-C� Jl� c S , t 44ITelephone L/ /3 (c/
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M:G:L. c. 452, § 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 (11 No ❑
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
SECTION 5- DESCRIPTION, OF PROPOSED WORK (check all applicable)
New House ❑ Addition fJ Replacement Windows Alteration(s) IN Roofing E
Or Doors 0
Accessory Bldg. 0 Demolition 0 New Signs [0] Ceas [C sidi::y [DJ Other [Di
Brief Description of Proposed C `-e- - N e vA ZU� `'^ F ∎ C - . _ , , 3 5 k 3 1 1 i4 i ^ o` n u tA e J 5 1/1.c —
Work: 1.6 x a 1 '
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes V No
Plans Attached Roll - Sheet
64 .-If Nevin otisi ° Ani ,r ii:ldit .a ta tlri lio in h ;'dO f l"ete t .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
1, Ze - /4'fc r , as Owner of the subject
property
hereby authori-ze / ' CSC-` 1 4 4 4 t t
to act o. - . v alf, in all .. •tters relative to work authorized by this building permit application.
9zoo
Sig -ture o Owner Date
I, lee G , 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 .ains and penalties of perjury.
Print N
Signature of Owner /Agent Date
Section 4. ZONING ALL Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
P1/4' This column to be filled in by
Building Department
Lot Size
Fronta*e
Setbacks Front
Side L:- R:5 L: _
Rear
Building Height
Bldg. Square Footage 5
5 _
Open Space Footage
, 0
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill: 5
(volume & Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO (") 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 t DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 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 4)
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 Northampton Storm Water Management Permit from the DPW is required.
City of Northampton NOVO
Building Department
212 Main Street a it e
Room 100 ��ir� k�
U� North mpton, MA 01060 pats dfS�ottt�ktarr
fi1.d�R�o-& Y•'�,..ti� of � �'' r�� "�". �' �Y� a. x3 K 2 -F
�2 'one 413 -58 1240 Fax 413- 587 -1272
,i V
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ,
'ION Z = SITE. INFORMATION
This section to be completed by office
ropertV Address:
OAK. S T• Map Lot Unit
L O (ZEN C Q 0 (p .Z °Zo Overlay D
Elm St. District CB District
:TION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
-
Owner of Record:
Lc ( LD5C , liPAt: : ') 4dd,WSJ
ne (Print) Current aiiin Addres
303 tS / y
Telephone
inatur
2 Authorized Agent:
ame (Print) Current Mailing Address:
gnature Telephone
ECTION 3 - • ESTIMATED CONSTRUCTION COSTS
am Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
Building (a) Building Permit Fee
Electrical 0 (b) Estimated Total Cost of
�J Construction from (6)
Plumbing Building Permit Fee
Mechanical (HVAC) O
Fire Protection /I-- 5
Total = (1 + 2 + 3 + 4 + 6) Check Number
This Section For Official Use'' Only
Date
uilding Permit Number: Issued:
ignature:
Building Commissioner /Inspector of Buildings Date
)10 -0272
dT /CONTACT PERSON RUSSELL MANZ
/PHONE P 0 BOX 485 BERNARDSTON (413) 775 -3126 ()
i Y LOCATION 46 OAK ST
PARCEL 002 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
G FORM FILLED OUT
d
ig Permit Filled out / y35 4 ✓ `/ 5
id
f Construction: FINISH ATTIC SPACE FOR OFFICE, 3 SKYLIGHTS, 1 WINDOW, INSULATE &
,TROCK
Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
lding Plans Included:
Owner/ Statement or License 81403
3 sets of Plans / Plot Plan
3E FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
1FO ATION 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
//et Demolition Delay
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.
BP- 2010 - u�,
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
/10 -0272
10- 000349
PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
RUSSELL MANZ 81403
545.28 Owner: MINTZ LISA S & LEE FELDSCHER
Applicant: RUSSELL MANZ
AT: 46 OAK ST
'ess: Phone: Insurance:
(413) 775 - 3126 0
TONMA01332 ISSUED ON:9/14/2009 0:00:00
FORM THE FOLLOWING WORK:FINISH ATTIC SPACE FOR OFFICE, 3
S, 1 WINDOW, INSULATE & SHEETROCK
IS CARD SO IT IS VISIBLE FROM THE STREET
Plumbing Inspector of Wiring D.P.W. Building Inspector
md: Service: Meter:
Footings:
Rough: House # Foundation:
Driveway Final:
Final:
Rough Frame:
Fire Department Fireplace /Chimney:
Oil: Insulation:
Smoke: Final:
KRMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
a ITS RULES AND REGULATIONS.
ite of Occupancy Signature:
Date Paid: Amount:
9/14/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
BP- 2010 -0272
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
idinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
P- 2010 -0272
S -2010- 000349
0
PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
RUSSELL MANZ 81403
12545.28 Owner: MINTZ LISA S & LEE FELDSCHER
00)/ Applicant: RUSSELL MANZ
AT: 46 OAK ST
address: Phone: Insurance:
485 (413) 775 - 3126 0
DSTO NMA01332 ISSUED ON: 9/14/2009 0:00:00
sRFORM THE FOLLOWING WORK:FINISH ATTIC SPACE FOR OFFICE, 3 ,
NTS, 1 WINDOW, INSULATE & SHEETROCK
:HIS CARD SO IT IS VISIBLE FROM THE STREET
r of Plumbing Inspector of Wiring D.P.W. Building Inspector
round: Service: Meter:
Footings:
Rough: House # Foundation:
Driveway Final:
Final:
Rough Frame: /C " / / r� MI
Fire Department Fireplace /Chimney:
I
. Oil: Insulation: D V1 /0 , 5.09 , •,
Smoke: Final: G2kC' / 1 - L 0 - O 7 -- -
PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
OF ITS RULES AND REGULATIONS, I
� �,
irate of Occupancy 7" Signature:
do/2
fpe: Date Paid: Amount:
g 9/14/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
d >