18D-010 4 .
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
iermits 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
1 ,
The Commonwealth of Massachusetts
=WrZta'r Department of Industrial ACcidents
l o, -.........„=. ,,
Office of Investigations .
600 Washington Street
Boston, MA 02111 . .
www.mass.gov/dia .
, ..• . ......
..:.
-Workers' Compensation Insurance Affida Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (BusinesOrganizationAndivien.o: GS 5 i, E 6 / 4 6 Si C
Address:
,A2 i cc e6,41.3
„ .."_.„,.
City/State/Zip: /VORA 4irt /0 6 - 74 Phone.#: 6 (-2 / '' -
„,./
Ar/
e u an employer? Check the appropriate box: • Type of project (required): i
03 r
1. I am a loyer with '2 •O I am a general contractor and I
o
6. 0 New construction
have hired the sub-contractors
employees (full and/or part-time).*
listed on theattached sheet. 7. 0 Remodeling
2. 0 I ani a sole proprietor or partner-
These sub-contractors have
ship •and have no e)loyees 8. 0 Denablition
ergiloyeesand have wOrkers' , .,•..
working for me in any capacity. 9. Ej Building ail.dition
NO workers' comp. insurance-
required.] • . 5. 0 We are a corporation and its 100 Electrical repairs or additions
3. 0 I am a homeowner doing all work officers have{xercised their . 11.0 Plumbing repairs or additions
-,
myself (No workers' conap. right of exemption per MGL 1-1.;.. .. .
12.0 .Koot repairs . •
insurance required.] t ' r. 152, §1(4), and we have no __, .
employees. [No workers' 13.11 Other
• .
• comp. insurance required.). . •
*Any applicant that checks box #1 must also fill out the section below showing their workers' companation policy information.
t Homeownera who submit this afEtdivit incHcating ” they are doing all work and then hire outside conndattn'b must submit a new affidavit indicating such.
1 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 brie employeeS, they must pruvide their workers comp. policy number.
. .
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
• , il A ( .1 1: ' '.
Insurance Company Name: 2 / 65/ /r( i —,/ ,-- 0 . . • • •
Policy # or Self-ins. Lic. #: W C----' .:2 - 315 -'.- , .,:4 / r2 -6 0 Expiration Date:
,, ) py,
Job Site Address : S co' oe:,z::; 4 0 ei; • City/State/Zip:VI/0 f.‹.://t A / ) U q,I /14-4
llirll
Attach a copy of the workers' compensation policy declaration page (showing the policy n_____er and p_ ation date).
Failure to secure coverage as required Udder Seetion 152 can lead to the iibPOSiti6ticif Criniiiiii penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of; STOP WORK -ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copyaf tins ointment inaybeforwardedt.o the OffiCe _
HWei thibIA for iiitiiiiiidi COVernieVelificarion.
,______ _ ___ ..,.. . .._ ...____ . . -- ... - - ,.. . - ---. - - _ .. ._ • ,- ... . ... _ ,--- _____-_,-,—,....,-___-__,.......
_ I do herebycertffr under the pains.and penalties ofperjmythat the information provid &Labovelsiine_anifiO mot
Sit.. .tur 2 d ----- - ,__A„,es,--- . - -. •■ • :th :• : • 4 id 0 .
Phone 0: 6714 i I • . ' - ' -
Official use only. Do not write in this tirea, tO be completed by ciiy or townOfficial
. ' .
•
City or Tovvii: '• PermIt/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical,Inopector 5. Plumbing Inspector
6. Other . E- . - .
Contact Person: Phone #:
_____
•
SECTION 8 =- CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
C',L>) 1J 75,24;.; oa6 F
Address / Expiration Date
2 c3/ /SKI) Signature Telephone j
H. e` tu. _ r 1. Not Applicable ❑
g L) Iry ,x)6 v r�
Company Name / Registration Number
1 / B.e- � /00 /,
Add Expiration Date
✓V�
d-' 4 % � / 4../ 0) d 6 U Telephone (� - 1 62 0
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidav' must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildi g 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 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 -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 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
SECTION 5- DESCRIPTION OF PROPOSED! WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roo g ❑
Or Doors
CI
Bldg. El Demolition El New Signs [O] Decks [1=1 Siding Other [0]
Brief Description of Proposed � f � r
Work: .i NS���� �0� � ! �� �% l� � o 1�12>
Alteration of existing bedroom Yes _ No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
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 U.a S e (�' /i r(; l� IL'
as Owner of the subject
property
hereby authorize — e�
-'V.e)'`1,-) L 75/0./4
to acyon my behalf, in all matters relative to work authorized this building permit application.
- 7 X74 >i 0 /l
Signature of Owner Date
1 L e U3) L1 L_, �,A,0 y , as G /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.
Print Name
..�-w -_.-- (I ----/5 I' 0-4 A) ao jl
Signature of -wivei /Agent Date
t `, r
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 / R
Frontage .E
Setbacks Front 1 I
e
Side L:: i R: — s L: � R: I
Rear 1 1
a
Building Height
i
i s 1 1 f
Bldg. Square Footage ET ° "'" --" % — ' E ( i
3
Open Space Footage ; % _ _ I
(Lot area minus bldg & paved 1 I ' —.,.�
parking)
# of Parking Spaces 1 1 L
Fill:
; S
(volume & Location)
,
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:,
4
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page! 1 and /or Document #
I. B. Does the site contain a brook, body of water or wetlands? NO 0 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 Q ,Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: 1 _ 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0
IF YES, describe size, type and location: s r
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.
SO 1 f 1
gsgt.:
City of Northampton :,aeot'Attgxygieti*totaivA,m,ii„-
Building Department :
'x4Vv -:';r,.pk,..ciwt,r7Tv,w,,f,''-iei.
212 Main Street r 04 t.irw — z
i i..:r2-i-iyxal.....-----tgr
v2f4, ', - e •*- p..-7.-1-4
Room 100 tt,;;j:::;;IZV;:: Z ';4,r':f.:;.,.::1
:
rthampton, MA 01060 ,t c,1
V.,,c ti
;i,
414Fri ;Tg
f ' . 44. - : , ;44;14-:-:-.4:4,,
,
' ph ,
the 413-587-1240 Fax 413-587-1272 ,., ,,, ,, 4
ilT
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
3 C‹)0K-6- 4 t, „---, Map Lot
ni0 6 b - ''''' 6.- < Overlay District
410 g, tit A kr‘e 1-0 ye 4
k '
) .- _ -Zone '
... 04' Camistrict
Et— -- District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
i s -- , 3 (7(1 /C- L'' . ti
, ( I (
/- —
Name (Print) 1 Current Mailing Address: /
- i 4 if-
i
e
` . ../ i k.,/c1V Telephone
4 ii
Signature
2.2 Authorized Agent:
), A t -) 7 3 4 fi V 84, j i /4 , i T3 f7f
Namelp_int)
Current Mailing Addre
r
....,...c...---____)---` * 7
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use °nil(
completed by permit applicant . t Fee
-, nii
1. Building (a) Building Per
i I .) r ),' -
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing _ Building Permit Fee
4. Mechanical (HVAC) _
5. Fire Protection , 47 2/5-6 2 ii ,—
6. Total = (1 + 2 + 3 + 4 + 5) 9 ' 7-2 Check Number ' 4 1r %® 4- 3 5
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
a
BP- 2011 -0606
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- 2011 -0606
Project # JS- 2011- 000970
Est. Cost: $1050.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R SIDING 026846
Lot Size(sq. ft.): 14984.64 Owner: CARTER LEWIS G & JOAN C
Zoning: URB(100)/ Applicant: B & R SIDING
AT: 3 COOKE AVE
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586 -4167 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:1/4/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL VINYL SIDING ON FRONT OF
GARAGE
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:
FeeTvpe: Date Paid: Amount:
Building 1/4/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner