17C-249 (2) .•r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 1 08.3.4 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 fatnily
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 holm owner
exemptron; ° act as their own constraetion 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/footines (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
� ermits 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 nte:
Date
Address of work
location
1
The Commonwealth of Massachusetts
• _* . Department of Industrial Accidents, . ,
_► _ Office of Investigations '
e _ t i r e= 600 Washington Street
Boston, MA 02111
�t , www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricia ns/PIumbers
Applicant Information Please Print Legibly
Name ( BusinessfOrgamzation�lndivid� ): u .) I9 51 / 0 .S 2-E' .s ,
Address: I & & ) (-1 , �C ' b A 40 . ; • .
�
City /State/Zip: i4 1? 4 i,,r, C) T -) � ' Phone. #: 6 -1-//b (1
Are y an employer? Check the appropriate box:... Type of project (required): /r
1. am a employer with 4. , I am a general contractor and I
= * have hired the subantraetors 6 -0 costruction —
employees (full and%i parffime�:
2. .0 I atn a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ,
These sub-contractors-have ship and have no ealoyees S. ❑ Demolition •
working for me in any capacity. ac it3t employees and have workers'
# 9: 0 Building addition
[No workers' 'comp. insurance comp. insurance-
r • et 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
equ ]
3.0 I am a homeowner doing all work officers have - exercised their, . 11.0 Plumbing repairs or additions
r of ez tion' per MGL
myself [No workers' right P p 12.0 Roof repairs
insurance required] t c. 152, §1(4), and we have no • .
employees. [No workers' , 13.LJ Other
• comp, insurance regUired.].. .
* Any applicant that checks box #I must also fin out the section below showing their workers' compensation policy information.
t 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 - contactors 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: 4 i l} F rz i )7L'4(. x CO •
• Policy # or Self ins. Lic. #: W ( vi _- j0 ° o l7 % ' J I Expiration Date: O0 - " 1 J '`, 01 2 '
Job Site Address: 11 44 /1/ t` ✓ r City /State/Zip :' r d. 1c 2 t - L i � , .14/1 A ( 0 ��
Attach a copy of the workers'' compensation policy declaration page (showing the policy nu 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 ofperjury that the information provided above is true and correct
-- -Si-e ■ ' IJ -/Lpi � D8tC: ) , ✓ V' /2"
tune: ,
Phone ii: 6 f 'J ,; _ _ . 7
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 +- r
Contact Person: Phone #: II
SECTION 8 - CONSTRUCTION SERVICES
-
8.1 Licensed Construction Supervisor: // Not Applicablrr ❑
Name of License Holder : 7 3 /Zit h2
License Number
_2Z / J),cc
Address Expiration Date
C7 �� l�, � T�� I/4/ oJo r
Signature Telephone 0 b/
�j 1
r Not Applicable ❑
mac <�i d i�� <> � / "��
Company Name ✓i Registration Number
%eke - £ /ol>h
Address Expiration ate
A)0 7- 4 '7Tt1A ) � OJd /, 0 Telephone gg 67
—
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG L. c 152, 25C (6))
Workers Compensation Insurance affidavit must be completed and submitted with application. Failure to provide this affidavit will result
in the denial of the issuance of the buil ing_permit.
Signed Affidavit Attached Yes No ❑
ific “Iv
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 1
1
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
w
New House [D Addition ❑ Replacement Windows Alteration(s) ❑ Roofing El
Or Doors ❑
Accessory Bldg. ❑ Demolition El New Signs [O] Decks [C] Siding [[ Other [0]
Brief Description of Proposed
Work: 1 N 3 rA // L N 7'i .`� /L, P
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. Wftl,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, /1 /d ) ( 1 QJ U 1Z r; [ j , as Owner of the subject
property
hereby authorize E4 co i A) Z • &eAC'
to act on ehalf, in II matters relative work authorized 16y this building permit application.
v � ' it ,/u. ) �� 1 / 2' l
Signature of Owner Date
1,
1 Lk) i13 /_ • TS ,af1Q
as Qisr/Authorized
Agent hereby declare that the statements and inforniation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
)2.wr L T 4
Print Nye
Signature of G!roser /Agent , Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Inforrrkati :.
• Existing Proposed Required byZotiing _
This column to be filled in by ' ` S » C; "
Building Department
. .4
I I1 I 41
' Lot Size
Frontage 1 1 1 1 l @
Setbacks Front 1 1 1
Side L:[ I R:i L: R:1 j i
Rear [ 1 1
Building Height 1 E I 1
Bldg. Square Footage I 1 1 1 % 1 I 1 1
Open Space Footage - _% _..._ j - _ `_ 1
(Lot area minus bldg & paved -
parking)
# of Parking Spaces
Fill: t
(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: 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page I and /or Document #1 i
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 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 size, type and location:
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
', ,
r _ r € a' vs a § a
:+�41'L4i City of Northampton � l j
Building Department
212 Main Street
Room 100 .4 , " r : 14 1 g � z:
i. I i Northampton, MA 01060 �; ." � �,f : - ' - :. i ; i. ;- ° �
OF BUILDING INSPE • . ne -13- 587 -1240 Fax 413- 587 -1272 "3., i s .„2 , ; A
NORTHAMPTON MA 010:0 �,: %,- � � - ;. t
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
,�,) 4 r> S M apk� "lot '1..,=.3 z u
on e £ 3 „ Overlay cs 7c
ji ; 4.. Of0 3
�� � U � +Elm!St. Distrlci . e q 'tC & dist ri ct
SECTION 2:- PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
4 p0 ,eE� rit ., ,? �� %p
Name (Print) �7 Current Mailing Ad r
v / g ) T 1
Signs ure 9/3 Y .4 ? '' V d‘
2.2 Authorized Agent: /
L l Ai i >~) L'� 75 ime .( ' _:s' e �k' gis / ' ,�. -�7 j �^ 7 l 4 72 0J lin X
Name (Print) Current Mailing Address:
,..._.7 1 . � - ` . t_ ' .5-9/ q //7
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Offic Use Only
completed by permit applicant
1. Building iqr , a (a) Building Permit Fee
/ `9, . yo
2. Electrical (b) Estimated Total Cost of
, Construction from (6)
3. Plumbing _ Eluliding Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) ' J 5. 0 l ' ; Check Number s ® /I p —
This Section For Official Use Only
Date -
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector . of:; Buildings;: Date
61 NORTH MAIN ST BP- 2012 -0688
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C - 249 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit # BP- 2012 -0688
Project # JS- 2012 - 001207
Est. Cost: $19240.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R SIDING 026846
Lot Size(sq. ft.): 21780.00 Owner: CHURCH ANDREW
Zoning: URB(100)/ Applicant: B & R SIDING
AT: 61 NORTH MAIN ST
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586 -4167 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:2/1/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL VINYL SIDING
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 2/1/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner