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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 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
ations The- spection 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
building department requires these inspections before the work is concealed, failure to
secu 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 buildingrpermitissued,_ 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
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.
Address of work
location
The Commonwealth of Massachusetts
Department of Industrial Accidents
I = t'li'�lt — z Office of Investigations
° l' 600 Washington Street
Boston, MA 02111
' ow s www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information _ Please Print Legibly
r
Name ( Business /Organization/Individual): 7.4 Al / ' i
Address: / S rY y 7r ; �lbtli°Gzc'p / .
City /State /Zip: crarekleC / A 61l2 Phone.#: 9/ y ' C7 e 5' --- # '6
Are you an employer? Check the appropriate box: Type of project (required): 4. I am a general contractor and I
1. I am a employer with 6. ❑New construction
employees (full and/or part- time).* have hired the sub- contractors
2.ani a sole proprietor or partner- listed on the attached sheet.
These sub-contractors h 7. Kemodeling
ese su- contractors ave.
ship and have. no Pilo; ees 8. ❑ Demo,on
for me in any capacity. employees and have workers'
working
Y P tY• 9. 9 Buildi a addition
[No workers' cor p. insurance CQInp__insUrance
required.] 5. 9 We are a corporation and its 10.0 Electrical repairs or additions
�. 0 J am efneowaer d a I work o 1c_exslza_v, ezci5 dJaeir�.- -- 11: P repairs or additions
myself [No workers' comp. right of exemption per MGL 12.9 Roof repairs .
insurance required.] t V c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.].
*Any applicant that checks box #1 must also fill 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 - contractors and state whether or not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
Iam 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 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fin!
of up to $ 250.00 a day against the violator: Ile 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 pent lhps of perjury that the information provided_ above_ istruenndcorrect. __- __ _
/ , �j�
��
Signature: . �..;. � ��/ _- Date: Z y/ �(
Phone ##: 1l 3 ._ 5 • — l C`_.
- Official use only. Do not write in this area, to be completed by city or town officicL
City or Town: Permit/License #
Issuing Authority (circle one):
- I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical_ Inspector 5. PIumbina Inspector
6. Other
Contact Person: Phone #:
' i
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Suurry v isor: ��p� Not Applicable ❑
Name of License Holder : ( S604?/ /� < G ` / ' r License Number
/� cyU' i7 f.- n4 O7OiZ / V.?0/20//
A s
Add , Expiratio nature �elephone
9: Registered, Home .lmprovement°'COntractor', ..,R ,,. . Not Applicable ❑
‘(76/
Corn any Name ' Re Expir o n D % istration Nu
A ss w
A tr - t y 1 R `if 4'* Telephone ge i l l3 - SW .reG.S`
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 OK No ❑
The_current_exemption for "homeowners" was extended to include Owner 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 1083.5.1.
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 Sunervisur you! presence on the job site will be required from time to time, during and npnn
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
-- - ._--- ___ - . - :Laws- Annotated.
l ort ampton *Nina ces;'Sta ° .r . - . , , ,. .: , . • s General
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Er Roofing ❑
Or boors
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [[] Siding [D] Other [0]
Brief Description / o - f Propp -s-e�d, , "
Work: / / / f�td - p00 0 t eie - cike P (ola7i.4^2 / Oc3' -r (lvt� - tN6s. ei A' keidze,
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement No
Plans Attached Roll - Sheet
Ga If New house and or addition.to existir n housinq ;- complete`the`foilowinq:
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, C 4 Ittve Tan e S , as Owner of the subject
property ,o /`
hereby authorize • ` °t Xe ` d
to n y behalf, in all matt ive to work authorized b thi building permit application.
1.2 4_0 114 572y/Zet//
Sign of Owner Date
I H ��� as Owner /Authorized
Agent hereby declare that the statements anation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under th pains and penalties of perjury.
4S X /1/7
Print Name �-
(77 - _5 20 /
Signatur ner /Agent Date
y .
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incom. ete Information
Existing Proposed Require. .y Zonin (;
This col • . to filled in by :fi
Building , epa�
LotSize _ _ . r._.._,... ..,....._ ' " _,,. _ ._ .._._ . irr,y . ,
Frontage
Setbacks Front
Side L.__. R.__ ___'
Rear
Building Height
Square Footage %
Open Space Footage
(Lot area minus bldg & paved
# of Parking Spaces
Fill:
(volume & Location) _>
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO (25 DONT KNOW 0 YES
IF YES, date issued:: _ l
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book _ Paged and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 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 ally signs exist on the property? YES 0 NO
IF YES, describe size, type and location: ,
n` a r a fi � i P r P any prnpos ?d "r anges to nr a _ itinnS fen M f t the prnperty 7 YFS 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, a aviation, 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 errr�x
'OM .' uilding Department
r a 212 Main Street 5etve tiqA Cab�it� �
Room 10 0 1 ��
1 .17 ; 0 a "hampton, MA 01060 T is ® t
= ...0 ;;0000 0 .
•ne 413 -587 -1240 Fax 413- 587 -1272 ft ite. ins f '
OgeSp40 A 0& A v y
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address: I��
.-- card/ .1464 U�ty Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of / Record: / / / f--/
Na p1P • t) Current Mailing Address: eyo 6
Telephone
Sure
2.2 Authorized Agent:
Warn nnt ` Current Mailing Address: 0 /
-
Si • - - - l Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building f✓ (a) Building Permit Fee
� r
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fci:
4. Mechanical (HVAC)
5. Fire Protection
6. Total (1 + 2 + 3 + 4 + 5) Check Number g� 1 ;x/1
This Section ForOff"rcial Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0963
APPLICANT /CONTACT PERSON C & T CONSTRUCTION
ADDRESS /PHONE 15 Fairway Drive FLORENCE (413) 586 -4965
PROPERTY LOCATION 23 CARDINAL WAY
MAP 36 PARCEL 344 001 ZONE SR(100) //WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT 1,
Fee Paid
Building Permit Filled out 2 1 �� ('i
0
Fee Paid 4 ✓ ��7
T j.eof Construction: FINISH BASEMENT BATHROOM XERCISE /GAM ROOM
New Construction - S - -L' a) F l A` t r ► V
� f�T (AM �. � S
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 161761
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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 Permit DPW Storm Water Management
Demolition Delay
6i ii
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.
23 CARDINAL WAY , BP-2011-0963
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 344 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- 2011 -0963
Project # JS- 2011- 001579
Est. Cost: $25500.00
Fee: $153.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: C & T CONSTRUCTION 161761
Lot Size(sq. ft.): 30361.32 Owner: JONES CHRISTINE
Zoning: SR(100) / /WSP II Applicant: C & T CONSTRUCTION
AT: 23 CARDINAL WAY
Applicant Address: Phone: Insurance:
15 Fairway Drive (413) 586 -4965
FLORENCEMA01062 ISSUED ON:6/1/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:FINISH BASEMENT
(BATHROOM,EXERCISE /GAME ROOM) - NEEDS RECORDED AFFIDAVIT AT FINAL
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 6/1/2011 0:00:00 $153.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner