23B-029 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
buildin department requires these inspections before the work is concealed, failure to
secure these inspections can result in: failure 'to obtain a certificate of occunancv
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 talne.
Date
Address of work
location
The Commonwealth of Massachusetts
Department of Industrial Accidents .
=_;►�_ E Office of Investigations •
600 Washington Street
� Boston, MA 02111
wwx. /dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): Soy
• Address: � So - - k 4M , -- -
City /State/Zip: POI-44 j4 .0 f 010 < Phone. #: -
Are you an employer? Check the appropriate box:. • 'Type o f prgiect (required): 1
4. am a general contractor and I '
1. [] I am a employer with ❑ I g 6. New construction
- - - - - - -- lo ees full and/or art time
* -- -have - hired - the - sub-contractors
- - - - -� -
a sole proprietor or partner listed on the attached sheet. 7. Remodeling
ship and have no en ioyees These sub- contractors- have . . 8. [] Den olition
working or m i n an aci employees and have workers'
S YP t3' 9: 0 Building addition •
[No workers' comp. insurance comp, tnm„ a;,r�.t
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
e
h
fficers ave.xercised their
3. E] I am a homeowner doing all work o , 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 belowshowing their workers' compensation policy information. '
t Homeownert who submit this affida indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors th check this box must attached an additional sheet showing the name of the sub = contractors and state whether o 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 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 penalties of perjury that the information provided above Ls true and correct
— ttue _. • Date: i i 1 ! _ •
• .
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,lnspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #: �I
SECTION 8 - CONSTRUCTION SERVICES '
8.1 Licensed Construction Supervisor. Not Applicabl€ ❑
Name of License Holder :N I *��
( ,_ / J License Number
.5 c• 4( /t( u S � - ` f -{ �r� e . (r"°� -G� 0 5
Addre s Expiration Date
Nowno ...111111111N _ 4 —3 3'
Si Mi re Telephone
Not / Applicable /p ❑
{ G r� fi10 3
Company Nam - Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS'. COMPENSATION INSURANCE AFFIDAVIT _(M G L. 152, jIi SC(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 ❑
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 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) J Roofing El
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [I=J Siding [D] Other[) J
Brief Descriptipq of ?foposed ,i j I ( L
Work: f` l _
, v �.t o �-�� �^\ K-i t/ + �v1'S•F+r< .>
Alteration of existing bedroom Yes No Adding new bedroom Yes _ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
a. � r� . + "
�� " " _m ® , a' t �®
,e as -� � te
�� t ® i n W:AthB.
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. Wi[Lbuilding conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION la - OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I Ea , V 3 C c- g r / , as Owner of the subject
property ' i _' v-A hereby authorize % -r �O J ? OR.
to act on my behalf, in a I matte relative to work authorized by this building permit application.
( / 7 f4/2- Eyi
Signature of Owner Date _
1, NG-iN .T t -C�_.a , as Owne uthori
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 NNme
Sig =t re of Owner /Agent Dat
. .
.. ..
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required Zorying
This column !o be 'led in by i
Building D artm t - ■
.. . I
,.,,,,,, ,. -~•,-, - j
Lot Size 1 I
• I I a ___________I
Frontage I
_
Setbacks Front 1 . =
Side L:= R:= L:= R:=1 = =
Rear 1 1 11 11
Building Height
1 1 E 1
Bldg. Square Footage
1 j [ 1% 1 1 3 =1
en Space Footage % --
(Lot area minus bldg & paved 1 1 = 1 1 1 .1
parking)
# of Parking Spaces = ,
i 1
Fill:
't
(volume & Location) 1 i
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Z... YES 0
i
IF YES, date issued:1 I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW a YES 0
IF YES: enter Book Page I and/or Document #1
1 ,
B. Does the site contain a brook, body of water or wetlands? NO la 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
0 , Date Issued: , I
C. Do any signs exist on the property? YES 0 NO "(a
i .
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
IF YES, describe 7 escribe size, type and location: I
1
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 ID__
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
• ,
{ sly of Northampton °
pW 3 , 9 _ y
B ilding Department ,
.0 k 3 201 E' ' 12 Main Street 1`�� ',
Room 100 �? ,, '
ceo ► • - mpton, MA 01060 , .a� 6 . - � �
� '�: one 413 - 587 -1240 Fax 413 - 587 - 1272
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
f 6.- r ." ip F it -Unit'
.4--LA ct '? . C.O (O ic,: -. �ye>'kaj� is c .
Et t:' -'- ilia` ,i . . , iCBDistxrct '
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT .
2.1 Owner of Record: c j °�
/Ed e.-.- 7 .J c 3 . c G. 5 , G / f 4, /J 4,.. S N o r ; 6,----(,..-3 70 ...I ,"t fit-
Name (Print)
Current Mailing fling Address: 7 y 6s of l 3 S�
`''�'" ` Telephone
Signature
+b
2.2 Authorized A f // _l
L1 1,� ~`J c�/1� <L 1.7� 1 V�'le' .� t 7' v'e&&C.{7 Lac i
Na (Print) Current Mailing Address:
� (-C i 3 �l -- ` - (9 ----- 3Y3/
Sig ature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS ...
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ? X00 `v G (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
l S 0 a L Q Construction from (6) -
3. Plumbing Building Permit Fee
l ` co °
4. Mechanical (HVAC)
rl
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) l i TO t7 Check Number // 77 0
This Section For Official Use Only
Date
Bu ilding Permit Number Issued:
Signature:
Building Commissioner /IrisReCtorof Buildings - Date
File # BP- 2012 -0657
APPLICANT /CONTACT PERSON HENRY J SOUZA
ADDRESS/PHONE 62 SOUTH MAIN ST FLOREN CE (413) 949 -3431
PROPERTY LOCATION 16 DANA ST
MAP 23B PARCEL 029 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out �J " 4 0 ,
Fee Paid /
Typeof Construction: REMODEL KITCHEN & INSTALL 2 EXT REPLACEMENT DOORS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 087984
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
Demolition Delay
1//3/
i Z
Signature of Building Official Date
g g
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.
16 DANA ST BP- 2012 -0657
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23B - 029 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0657
Project # JS- 2012- 001127
Est. Cost: $11500.00
Fee: $69.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HENRY J SOUZA 087984
Lot Size(sq. ft.): 12545.28 Owner: SCAGEL EDWIN J
Zoning: URB(100)/ Applicant: HENRY J SOUZA
AT: 16 DANA ST
Applicant Address: Phone: Insurance:
62 SOUTH MAIN ST (413) 949 -3431
FLOREN CEMA01062 ISSUED ON:1/18/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN & INSTALL 2 EXT
REPLACEMENT DOORS
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 1/18/2012 0:00:00 $69.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner