18D-015 • • M
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
jermits 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
-de understand the above.
(Home owner /r ident's signature requisting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date 9
Address of work `
location V � (/9Q f a t— G t {r1' -e
` 7� / /int 6 ��� n
7
The Commonwealth opfassachusetts
Department of Industrial Accidents •
Office of Investigations
t Nifittl.-- @ 600 Washington Street
... •=4.1=- O Boston, MA 02111 . •
1.•... v--...- .",
•-*....„,,,,r..-..- - , www.mass.gov/dia .
_..
•
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information pkse p -t Legibly rin
Name (Business/Organiiation/Indivienni): ) J,,..,-...e
f
(.7 ..____ p _
- . Address: ni
/ Ato act
City/State/Zip: i i\P / J - ---- c_D Q
Phone.#: Yi.._ - --C g , C -.--
Are you an employer? Check the appropriate box: Type ofproject (required): /
1.0 I am a employer with 4.. 0 I am a general contractor and I
6. 0 New construction
have hired the sub-contractors
employees (fall and/or part-time).*
listed on the attached sheet 7• 0 Remodelinz,
2.0 I am a sole proprietor or partner-
These sub-contractors have
ship and have no . ..:Ioyees .8. 0 Demolition
working for me in any capacity euAilo_yees and have workers
9. -EjBundink micaitin
-, ;_ . _ _
[No workers' comp. insurance _ con3p.s,c
)( o
I am a homeowner d6ing all work
required.] - . . 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
officers have -4xerciserl their . 11.0 Plumb g repairs or additions
3. 1-
myself. [No workers' comp. right of exemption per MGL 12.0 ' • • f repairs . -
insurance required.] t • c. 152, §1(4), and we have no
employees. [No workers' 13.1, Other .0. • V<,
34.0
" . comp insurance required-1 - 4 P c a 47iriorn- .
*Any applicant that checks box #I roust also fill out the section below showing theirworicers' compoisalion policy infonnation.
t Homeownera who subruit this aiftda 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 employeea, they must provide their workers' comp. policy number.
1 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"(shovving the policy number and expirotion date).
. .
Failure to secure coverage as required 'ilia& Seciiiiir 25A ofMGL c 152 can lead to the iinpOsitiMi of penalties of a
fine up to 51,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WOP.IC-ORDER and a fitie
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
Bii.onsOf the for insurance ecwerizeirerificon. - _. ..._
_ I dii hereby , tifr under the pains.and penalties ofperjury mat the informationprovidirtaboveis_true_azideorrper
9 (
Sienature: , --el yigi - t OdeAjt-4 - Date: .
ph ii CI -
Official use only. Do not write in this area, to be completed by city or town 'official
. .
City or Town: "- Permit/License # '
-.............
Issuing Authority (circle one):
.1. 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: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
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 ❑
11. - Home Owner Exemption
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
l.- 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, Sta t nd Local Zoning Laws and State of Massachusetts General Laws Annotated. }
Homeowner Signature A. %' ,e.. ri ,(„4,.( i ,. &/A. ..� 41,44,4,,,‘
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) I Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [I= Siding [0] Other [D]
Brief of Pfopg7eix+- , r
Work: 1/1/0 !L YaCLt'YI jh 'D tic Ta -cp49 (: tZif" 'f `1 oat SGT rr--e
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 existing housing., complete 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
I • (Y\1 , as Owner of the subject
property
hereby authorize V0a Yy`t?_s
to act . y behalfin all matters relative to work authorized by this building permit application.
/ !
Sig'ature of Owner / Date
I,.Q- - vtl.. � L_ (}1. `�f , as Owner /Authorized
Agent hereby declare that the statements and information bhlhe foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
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
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: ' L:. _ R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /o the site?
NO 0 DON'T KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW YES
IF YES: enter Book ! Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 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 NO
YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavatio -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.
A
Dep use only
Ckty of Northampton Status of Permit:
,01a Su' ding Department Curb CuttlDriveway Permit •
ti� ? , 2 Main Street ewer /Septic Availability
‹-, -, Room 100 Water/Well Availability
Northampton, MA 01060 Two ;Sets of Structural Plans
phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site °Plans
, '
• Other Specify
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
� - Y +1� `�� �� Zone Overlay District
EIm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
�° r r Current Mail n Address:
/
Name t)
(105
�f` s
./A/51 h } Telephone
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
completed by permit applicant
1. Building lj .7° (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) Check Number //5
/
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
49 PINE BROOK CURVE a 4 BP- 2011 -0281
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18D - 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-2011-0281
Project # JS- 2011- 000469
Est. Cost: $750.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 15202.44 Owner: ISERNHAGEN DENISE J
Zoning: URB(100)/ Applicant: ISERNHAGEN DENISE J
AT: 49 PINE BROOK CURVE
Applicant Address: Phone: Insurance:
49 PINE BROOK CURVE () 582 -9058 ()
N O RTHAM PTO N MAO 1060 ISSUED ON: 9/27/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WOODSTOVE
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 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
6