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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 fandly
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 owl constrnetion 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 backfdl)
sonotube holes (before pour), a rough buildinginsvection (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 in pections 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
mde
a --0 /Go cCn P Z ( C4fiecem, t+tinderstand the above.
(Home owner /fesident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date S'; Z 7 - Z
Address of work
location / 7) Ilan- }47/,
rt-i--eA4 Geo "4
a/0
, ,
The Commonwealth oPfassachusetts
Department ofIndus Accidents • ,., .
it . " =.... ........7.... in
='!4#1== El'' Office ofInvestigationS
tri 600 Washington Street
Lif—" Boston, MA 02111 . . .. -..a-
www.mtzss.gov/dia
, ... • •
•
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information . Please Print Legibly
Name (BusinesS/Organiiation/Indivichini): ,
. .
. - :, - .. •
,
" • Address: i f 7 / /0, / 3/ ,. • ..
r -1
City/State/Zip: 7 (r). 71- 01.0(061 Phone.#: ( - 4 06 g -
3 V/ 3
Are you an employer? Check the appropriate box: - . •Type of project (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 (full and/or part-time).*
listed on the sheet. 7. 0 Remodeling
, 2.0 I am a sole proprietor or partner-
hese sub-contractors have.
. ship and have no elloyees T •8. 0 Deitiolidon . .
working forme m any capacity . krm)loyees- andhave wOrkers' . -.. . ,.. -
9: used* allchiadri
[No workers' comp. insurance - comP--irance-- - -
. required:1 , . 5. 0 We are a corporat 100 I4ectrical repairs or additions
ion and its
3. I am a homeowner doing all work officers haVeticerCised the 0 ir .
. / 11. Plunibing repairs or additions
(
myself [No workers' cOnv. . right Of exemption per MGL 12.0 Roof repair' s . •
insurance required:1f
. : p. 152, § 1(4), and we have no - ,
'
. employees. [No workers'. . 13:-L-1 Other
1 . . . • . comp. insurance reqiiired.1. - . • • . : I .
•Any applicant -that checks box amust also fill out the section belovishowing theirwodcers' compensation policy information.. • . -.1: .
1. Homeovnicai who submit this afftdaiitinridating they are doing all work and then hire outside contactors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sbeet showing the name of the subr-contractors and 'gat e whetherarnottliosec ;Aides have
employees If the sub-contr-actors haVe employees; they must provide their workers con p. poHcy number.
lam an employer that isproviding workers' compensation insurance for my employees Below Ls the policyand job site
information. • - .
, . .
insurance Company Name: • . - .
. .
- - .
. .
Expiration Date: - .. - •
Policy # or Self-ins Lic. #: .
. .
. ,.
Job Site Address: . • . . . City/Siate/Zip:' • - . -,• • . _ - ;
Attach a copy of the workers' compensation poliey declaration pago(showing the policy minibe.r and expiration date).
Failure to secure coverage as reqtdredinidtir Seel 25A 152 can lekt to the iiiii Oiliiini OfCiiining Penal ties of a
fine up to S1,500.00 and/or one-year implisonine4' as well as civil Penalties in the form of a STOP WORIC-ORDER ancla fine
.. ., ..... .... ... ..
of up tO S250.00 a day against the violator Be advited 'that a copy Of this statement may be forwarded ta theOffiCelof . .
EFestmationS insurance cov&ant Veifficatioti . . . .. - . .-........ . - ., . ,-. •-,., .... ... , _.:
_ I dO : reby certifil under , . ,,. -and penalties ofperjury thaithe inforznationprOvittedsib.ovelt.tine.atid_Correa'
,400000
. . .
• ,.■ 01 .- -1.------>. , I ' - 2 ,f--- ?-7- - Le
....• lure- ___—_...0 -. .1 Al 1 i • ate-
. • '' 2 j .
Phone it: (---/ l c . '') — ? 1 - i / - - 40 7 --, . ' - .. .
: - Official use only. Do not write in this area, to be completed by city iii-thWn'officiaL
I I
. .
City or Town: Permit/License #
Issuing Authority (circle one):
*- . .
2. Building Department 3. City/Town Clerk 4. Electricalfaispector 5. Plumbing Inspector
. I .
. : Cnt
61: ar e fileliIll ' .
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:`Redistered,liomeI mprouemelnt "c tor ." ik E,.Z. . Z cial a • U,i ; w;',,•.. ,. „ 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 ❑
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 a • .n• ..• Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signatur • * - _ 1 , —1 vL i 4 /fit/ 'T'
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ® Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks Siding [D] Other [D]
Brief Description of Proposed, l / J�
work: TPoun9 S> Z/r!! --e-Y; J74 i'1 ��T . eve C £GrC t rep /su t / 0 A b
Alteration of existing bedroom Yes V No Adding new bedroom Yes / No •
Attached Narrative - Renovating unfinished basement Yes V No
Plans Attached Roll - Narrative ( --.., , ,,_
J
sa .-tf.l ewRhoiisealla;aic.aacli c n tOekistincl iiuitas>«r q,;'catmp ete.th faiic iilria:
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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
S ned under the pains and penalties of perjury.
eh rC r / " - kr 1"P - z. / 44-44 t�J /iv; ' '�
P rint Name /
• , - ero 9 e /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
d
1
Lot Size I ` I i 4
Frontage _ ___ ._ T f `
Setbacks Front i I 1 J f
Side L: R:! . a L: L._ I R:
Rear E
Building Height 1
1_
Bldg. Square Footage 1" I } } %
}
Open Space Footage % _
(Lot area minus bldg & paved i _ ? . -, ,..
parking) ,
# of Parking Spaces ,.
Fill: ( II 1 }
(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:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES 0
IF YES: enter Book ! Page[ and /or Document it:
_
B. Does the site contain a brook, body of water or wetlands? NO 4 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: 4
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO ire
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 0.4 4.
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
,
City of Northampton . � ` A
Building Department g , ; - � , , �- ' ``
G Gs 212 Main Street --9 � ' a " �� ' liter x $ - � ,
• ` Room 100 i - i.. �`�' � - 4
�\� Northampton, MA 01060 - . i „ , t z 1
3 • , on - 413 587 -1 240 Fax 413 -587 -1272 r m. a > - •
CIF ! ?� 1''' ION 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
/ 7 / A/ a f f , Map Lot Un
i s
(fal l() �, Zo ne Overlay Distric
" -e-n(_- 1Ft /
EIm St District CB District
C h�e .
pher R G'� L L�- Z—
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
i n - f ) • -f (A) f -- t - r ^ r) e. r
• 2.1 Owner of Record:
iiAi rij gdri, ii-e2 �>/ th Wrilitii /71 a>r / " /d.4 ✓1 ,5"fi
Name (Print) , Current Mailing Address: 2
ta�,�.trYiQ : 13 /v n �e , o . ca t 6 /c
,,b � Telephone G
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 / / 7 / 0 (a) Building Permit Fee
2. Electrical 0 (b) Estimated Total Cost of
Construction from (6)
3. Plumbing a Building Permit Fee
4. Mechanical (HVAC) D
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) /‘",6? d Check Number U V
This Section For Official Use Only
Date
Building'' Permit Number: - Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
4
File # BP- 2011 -0996
APPLICANT /CONTACT PERSON WITMER CLAI.DINE
ADDRESS/PHONE 171 NORTH MAIN ST FLOkENCE (413) 341 -3004 Q Y \�`
PROPERTY LOCATION 171 NORTH MAIN ST
MAP 16D PARCEL 018 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT r15
Fee Paid 1
Building Permit Filled out �% f (
Fee Paid /�'v
Typeof Construction: DOWNSIZE 2ND FLR DECK 20 TO 9' & REPLACE 1ST FLR SLAB W/WOOD DECK b
New Construction vo,d0
Non Structural interior renovations
Addition to Existing
Accessory Structure �'l?
Building Plans Included: F.,k'
Owner/ Statement or License # + � � ?l
3 sets of Plans / Plot Plan i U
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON nt'
INFORMATION PRESENTED: (Xt
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§ a „p
yam
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
Signature of Building Official Date
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.