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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 defmes "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 &Northampton wants person(s) who seek to use
the home owner exemption, act as their owirconstmttion supervisor; to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires thatthe building department be called to
inspect work at various stages, which include foundation/footings (before backfill),
sonotube holes (before pour), a rough buildinginspection (before work is,
concealed), insulation inspection (if reauired) 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 inspeeted.
If the homeowner hires other trades to perform work (electical, 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
• 1, • 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
Date •
Address of work
location
•
The Commonwealth of lfassachusetts
Department of Industrial Accidents.
gl Office of Investigations
� Y
600 Washington Street
=-411:!=-- • Boston, MA 02111
�t xww.massgov /dia
-Workers'. Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information r Please Print Legibly
Name ( Business /Organiiation/Individual): SCc, ( c (c c •
• • Address: / 9 3 /V L n 11
City /State/Zip: vc 1 f Phone. #: 7 c 6 ` 3 3 `
Are you an employer? Check the appropriate box:... Type ofprolect (required): /
4.. ani a general contractor and I
1. [] I am a employer with. ❑ I g 6 New
= = — * have hired -the sub- eontraetors— — -
constructi on
yees (full and/or part -fime).
2._ I aai a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling , •
sfi and have no employees These sub- contractors -have. . 8. ❑ Demolition
working for me in any capacity. ca employees and have workers'
$ . 9. 0 Building addition
[No workers'- conip. insurance • comp. insurance. 10. Electrical airs or additions
re aired 5. ❑ We are a emperation and its ❑ 1eP
4 ]
3. ❑ I am a homeowner doing all work officers havelxercised 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 requited].
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy inform ion.
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 .lens= 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 oae -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 . e coverage verification.
I do: hereby certify under , aim .and penalties ofperjury that the information provided above is true and correct
5_ignaiure: _ .D /
ate:
t
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 9, •
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : S C c tf &f t c /CC S 3 i, 6
License Numb r
, � uC .. 1/ �I LC uC,- f »i / /Q/ t-
Address / t c Jv y Expiratio Date
ture Telephone
Not Applicable ❑
S./4 /- 3 - 3
Company Name Registration Number /
VA0/ /(
Address Expirati Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G L. c 154 § 25C(8))
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 buildin it.
Signed Affidavit Attached Yes No 0
�� . •
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
•
SECTION 5- DESCRIPTION OF PROPOSED WORK (Check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[ Siding (0] Other [ID)
Brief Des Option tion of Proposed Work: B
Work: 7v. , 4.4 t� on 1" r - L� c r--� C t �vt c �- e1C se 1 1.. (� k. 1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
�� . � ". .. � • ... m a m_.s sI @� � >� ar n o . $� e 8 , e - ����� .�... �:
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 OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT •'
I, � Cg C- C C 1 S_ ( LL.. , as Owner of the bject
property''
hereby authorize .1 (1s I'1 N LtLt o-s'> �J
to act on m •` half, ' all matters relativ o work authorized by this building permit application.
v - 4 - /i /1 i
Signature of s ner Date
I, 11 4 G_ , as OwniAuthorized ..,}
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of My kr'bwiedge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Si • ' Owner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zo ,.
This column o be filled in by s
Building Department i
' Lot Size 1 . a Z -_
i _�J 1�Y��Yrt y
1
Frontage 1 I
Setbacks Front = 1 1
Side L:f 1 R:1 L:LJ R:1 1 FT L
Rear I 1 1 1 I 1
Building Height 1 1 1
Bldg. Square Footage = 1 '% 1 1 1 1 1 1
_Open Space Footage _- . %- - - —
(Lot area minus bldg & paved 1 1 l 1 =1 1 1
parking)
# of Parking Spaces Ali
Fill:
(volume & Location) t g
A. Has a Spec' ermit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES Q
IF YES, date issued:I
IF YES: Was the rmit recorded at the Registry of Deeds?
NO DONT KNOW Q YES 0
IF YES: enter Book I Page and /or Document #1 j
B. Does the site contain a brook, body of water or wetlands? NO QDONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
IF YES, describe size, type and location: 4
E. Will the construction activity disturb (clearing, grading, excav • n, 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.
City of Northampton
RE : uilding Department
CE�V�D 12 Main Street r�
Room 100 4
' o ampton, MA 01060
p one 13- ,87-1240 Fax 413- 587 -1272
APPLICA • L UCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION .:
This sectionto be completed byoffice
1.1 Property Address:
:3 � `1 -
� � .. /� ., ; Map � R " t:ot � z 44.a. Unit:
I CBDistriot
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT.
2.11 Owner of Record:
/ / / /� 7�
/ J C' � / - G C'c„ !w` 3� 1 1. U /v 444_ 7 �, J / r t.. '{ Ne4 / n 4 sl- A 4+
Na (Pri 1 Current fling Address: r
Telephone
Si ature
2.2 Authorized Agent '
S r; v � c /Cc (- o i'^ Le <.c . -e. /2,1 lcuc`r M
Name (Print) Current Mailing Address: , c / , '1
3— 6 -'3 y r
Sign- . =` Telephone •
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ( Buihiin Perirtit Fee
n0 it
2. Electrical (b) Estimat Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
•
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 6 Oct c > Check Number ,/ V (}
.. This Section For Official .Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings - • Date
File # BP- 2012 -0006
APPLICANT /CONTACT PERSON SCOTT NICKERSON 1 7/61
tR
ADDRESS/PHONE 197 NORTH LEVERETT RD LEVERETT (413) 896 -3347 ()
PROPERTY LOCATION 34 COLUMBUS AVE r` 0
MAP 38B PARCEL 126 001 ZONE URB(100)/ c -T FLAtJ
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid �' / 7
Tvpeof Construction: CONSTRUCT 6 X12 DECK
New Construction
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included:
Owner/ Statement or License 053156
3 sets of Plans / Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 Peimut DPW Storm Water Management
Demolition Delay
7 /!r /
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.
34 COLUMBUS AVE BP- 2012 -0006
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B - 126 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit # BP- 2012 -0006
Project # JS- 2012- 000012
Est. Cost: $6000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SCOTT NICKERSON 053156
Lot Size(sq. ft.): 9539.64 Owner: SPECTOR LEE A & REBECCA S NEIMARK
Zoning: URB(100)/ Applicant: SCOTT NICKERSON
AT: 34 COLUMBUS AVE
Applicant Address: Phone: Insurance:
197 NORTH LEVERETT RD (413) 896 -3347 ()
LEVERETTMA01054 ISSUED ON: 7/11/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: CONSTRUCT 6 X12 DECK
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 7/11/2011 0:00:00 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner