30B-065 City of Northampton
Massachusetts �,
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• DEPARTMENT OF BUILDING INSPECTIONS 4 3.
' ' 1°1, 212 Main Street • Municipal Building va
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 any 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
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
The Commonwealth of Massachusetts
Department of Industrial Accidents
" . Office of Investigations '
= pr . e=
-...� 600 Washington Street �.
k
sP� , Boston, MA 02111 r
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization /individual): +_, // - `AK ' Z�'
/ ,/ '
Address: 7 > �� LaZ . y
City /State /Zip: / I Phone # : 4____lf
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I
e ees (full and/or part- time).* have hired the sub - contractors 6. 11 New construction
2. am a sole proprietor or partner listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ['Demolition
working for me in any capacity. employees and have workers' 9. ['Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. 17 We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
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.
I Homeowners 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 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 25A 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. Be 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 pena 4 of perjury that the information provided above is true and correct
Si u ature: ._ _ �'"� Date: � ' ■
Phone #: -
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 #:
9
SECTION 8- CONSTRUCTION SERVICES
a .
8.1 Licensed Construction Su 'ends 9 �` '�� � C 7 �6/t Not Applicable ❑
�i _
Name of License Holder : / / 411` � '
/ a J ,� � Expiration Number
,f Address � _ Eation Date
t 4'
Sign ir Telephone T .%/
1 7 Jig / ,-/ - ice
2egisteed;Hoiii I provement Contractor• ' , ., Not Applicable ❑
Company Name // / f
Registratio Number
_2 _/
Address - Expiration Date
Telephone
1 SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G L c.'152, § 25C(6)) ,7
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 ❑
,
' -4 '
ni , r elnpti
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
•
4
SECTION 5= DESCRIPTION OF PROPOSED WORK (check all applicable) _ ,;, t. ,
,
New House ❑ Addition ❑ Replacement Windows Alteration(s) [ Roofing Fti ----------
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [0]
Brief Description of Proposed ) . '' Work: --, - Q��'�4.� ✓-� -- � ' , . 7/
Alteration of existing bedroom Yes o Adding new bedroom Yes N o
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa'xlfNeWj ousek'an dror`.addition., o existing? . ousi nq , Ecomplete the,Ffoliowi`rig:
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 OWNERAUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR. FOR BUILDING PERMI
I, , ( r ��d , as Owner of the subject
property
1
hereby authorize ■ r V ..e.i.,.‘,:tigiill
to act on my behalf, in all'v e re e -- • e to work aut :rized by this building permit application.
/dS .r/ d I ��� /:�' �
Si.0 re of Owner / Date Ai/j���/
I, k .,-A'1 '" , as Owner /Authorized
Agent hereby dec . 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 penaltie perjury.
Print N e /;* V
Signs re Owner /Agent Date
F .
i
4
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
e
Existing Proposed Required by'Z'oning
This column to be filled in by
Building Dep.irtment
I; ii i
Lot Size i ' t.
Frontage € i
Setbacks Front E 1 L___
Side L. R: L ; R i
Rear '
Building Height , ; 1 1
Bldg. Square Footage 7-1 I : % 1
{ 3 I
Open Space Footage
(Lot area minus bldg & paved I I 1 1
9
parking)
1 i i 1
# of Parking Spaces I
Fill: I ._...._ _ __ __ 1 ..___ . _._
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:: I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book 1 I Page! and /or Document #1
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 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: ! I
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: I
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.
�� vw. � e Deartr � eu t z tise#oniy,- rry irt
City of Northampton S tus� Psr#
2 0 11 . B uilding Department Ga ��` � tikewa�e
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DEC 2 9 �� � �� �;
212 Main Street Serer • icAya abu�la� i t �� �.
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roN NsPE oso Northampton, MA 01060 Tw e � t r u �l ais
phone 413- 587 -1240 Fax 413 - 51272 o SI a�� �°
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APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMA
This se ction #o be comp leted by office
1.1 Property Address: q, $ h . ?� x ,r i
Ma� - �.ht '^ ? Lot YZ r �� t :°@k 7 > -Unit k�„x �_ r
g. ' U( ,IF / , G ���� t6 p n w , a . 4 se?.z r t _ -. „ * `a t,- .
j Zone Ov DistrLc ,
a s'
.Elrn St District .' a" " , CB District : '`
SECTION 2 - .PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) C went Mailing Address:
$,7.;, ,� � � � , r,�_ Telephone
Signature
2.2 Authorized Agent:
Name (Pn t Current Mailing Address:
- 7 g
.........„..e404. __ ..,••"....:"
Signature Telephone
SECTION ESTIMATED' CONSTR COSTS 1
Item Estim Cost (Dollars) to be . .) , ff . , Official use Only
co I ted by permit applicant ,
1. Building (a) Building Perm F ee
2. Electrical G' (` (b) Est irriat dt Total Cost o
Co nstruction fro (6)
3. Plumbing B uild i n g Permit Fee'
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check.Numb dd
This Section For Official Use Only -' ,. ,_,_ __ ,.. . . i
- `Date -
Build►ng Permit N . Is sued:
/ '
Building c‘ ummissionedinspootor of Buildings Date
284 RIVERSIDE DR BP- 2012 -0616
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30B - 065 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2012 -0616
Project # JS- 2012- 001066
Est. Cost: $1200.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES ROBERTS 99404
Lot Size(sq. ft.): 6011.28 Owner: BERARD ERIN M
Zoning: URB(100)/ Applicant: JAMES ROBERTS
AT: 284 RIVERSIDE DR
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527 -6078
W ESTHAM PTO N MA01027 ISSUED ON:1/3/2012 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 1/3/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner