31A-198 (2) •
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 (it 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 me.
Date
Address of work
location
•
. The Commonwealth of Massachusetts
Department of Industrial Accidents
Office Of Investigations
15- � 600 Washington Street
Boston, MA 02111
www. mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /EIectricians /Plumbers
Applicant Information Please Print Legibly •
Name ( Business /Organization/Individual): wow / ' j hS eooF`flj _
Address: PO /3 Ni [07 iC) P 1t L4
Cit /Zip: Phone #: 11 ? — 77 _ G 6440)
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. [] I am a general contractor and I 6. New construction
e ployees (full and/or part- time).* have hired the sub - contractors
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. ❑ 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. ❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
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: rn ,S S 0,4
Policy # or Self-ins. Lic. #: // Expiration Date: doer4/900tof
Job Site Address: ; .--( 1 ( /As 1 V 1d A I .7 City /State /Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration da
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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLA for insurance coverage verification.
I do hereby •r, .f5' under the pains and penalties of perjuly that the information provided above is true and correct.
Signature: Al Li L/ I L JI Date: , _
Phone #: -413 7 7 (0 K7 q
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: I f� /� Not Applicable ❑
Name of License Holder : 1 " IJ F' "V A V � I 1 /,/'I t l xf / / bO 303
1111 h + License Number
r J Rue. 6v DPIA no ,3/7/`
Addr ss Expiration Date
I I i 11,3 "a` 14
' ignature Telephone
9. Re - istered Home Improvement Contractor . ," °; Not Applicable ❑
Q h J� �/1 �J R f� /� / It
Co a (�l Registrat ion u
£ 1 � 6 uw &s e 4-uC c5o 2b 2// 'M 7 1l3
A ess Expir ion Date
/ �/L Telephone 7 7g UG k g
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
as supervisor. CNIR 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 - vear 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, von 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) n Roofing EV
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [o] Other [O]
Brief Wok es crigtf ga Qf Proposed
O,1 YVt1 OAP P//O00 P/X1 fl4� 411 i6 \-70 yi o r)4'* 1,
Alteration of rr 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
S ION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
WNERS AGEN OR CONTRACTOR AP 'LIES FOR BUILDING PERMIT
_ �f 1 `lf �� ► �-1
I, , as Owner of the subject
p roperty
hereby authorize tt i 4 tf-a/t/ k
to act on my behalf n all matters r�424iae to k tti by this building permit applicon.
I VVV 1 1 7 Li ( 2i
Signature of Owner Date
I,
Y4 if°lit '1f U/ u J k I YI S , as /Authorized
Agent hereby declare that the st 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.
N tack '&1( ti / w1 lit s
Print Name
Signature of 4 'er /Agent Date aiYN1f1"
•
`-.
Section 4. ZONING AR Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
VDT a
Existing Proposed Required hy Zoning
This column to b'e in by a 0 .
Building Department
r --- ------~ '`~`^�
Lot Size
Frontage „
-. .
Setbacks Front �- �—_ �--
_ ��
- -
Side L: Il: �—__/
F -- --� �—�
Rear
Building Height F--- F--� �—_
_ _
Bldg. Squar Footage �--- / [ [---7 r----
Open Space Footage
(Lot area minus bldg &paved �--- F---- {---� �---� L__-�
parking
#uf Parking Spaces
�----� �--� �---
Fill:
(volume & Location)
A. Has a Spea1 Perrnit/Variance/Finding ever been issued fur/on the site?
0 ��
NO ��/ DON7KNOYY «�� YES v^~/
IF YES, date issued:
`----------
IF YES: Was th permit recorded at the Registry of Deeds?
NO DONT YES
� � _ __
"------ � r ----- ---
IF YES: enter Book Page < and/or Document #
-
x~_� � v� v�/ \
B. Does the site contain a brook, body ufvvateror wetlands? NO �^� »��/ DONT KNOKNOW � YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained x�� Obtained �-\ Da�e|ssued� � - ---------�
v�� �~/ , � L_____ - __ - _�
C. Do any signs exist on the property? YES K ) NO C;0
r ------ ------------------------ ---- - ,
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES /-� NO (E)/
IF YES, describe size, type and location:
E. Will the construcRcn activity disturb (dearing, ring, grading orfiUing) over 1 acre or is it part of a common plan
that wifl disturb over 1 acre? YES ) NO (L��
��
IF YES then a Northampton Storrn Water Management Permit from the DPW is required.
C GG �� Departntent use only
RGGG,v City of Northampton Stags of Permit
Building Department Curb OLit/D irrewa}r Perrnit
0 • A 212 Main Street Seuver(Sept[cAvaiiability
1
Room 100 UUaertUUe�A�a�labrtitr
sac 0 ► - - hampton, MA 01060 TwoSets ofStructui'al Piaris
54 J enne 413- 587 -1240 Fax 413- 587 -1272 Piott F la n s
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
gt/i
(411,5t1 � fi� �/ Map Lot Unit
fl 6 " `� Zone Overlay District 1
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: A ,�� flotl
5 tirkiii , -, /6-e - ,
1
Name (Print) ` - -""—' Current M Iin Ad /'�;/ /7 41:4k--- Telephone . 3 �a...
nature
2.2 uthorized Agent:
t A ic 1 fzOdFifr 00 soli, `07 5v OF
N i (Pont) Current Mailing Address:
�i ii.4
g i . re Telep ( 1/ 3
one
SECTION 3 - ESTIMATED CONSTRUCTION COSTS '
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 7°610 (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 / 74-5---69 5
This Section For Official Use Only
Date
Building Permit Number: ,, -..
Signature: !i " / /C � ��
Building Commissioner /Inspector of Buildings Date
54 WASHINGTON AVE BP- 2012 -0621
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 198 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 -0621
Project # JS- 2012- 001071
Est. Cost: $7000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HAWKINS ROOFING 100303
Lot Size(sq. ft.): 11238.48 Owner: MICK ANN F & CHARLES
Zoning: URB(100)/ Applicant: HAWKINS ROOFING
AT: 54 WASHINGTON AVE
Applicant Address: Phone: Insurance:
P 0 BOX 107 (413) 774 -6834
SOUTH DEERFIELDMA01373ISSUED ON :1/4/2012 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 1/4/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner