38A-015 (2) 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 ._ofNorthampton_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 proccess 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
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
---- - - - - - - permits -in- conjunction, to_the_building permitissued,_ 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 me.
mates____ _ ...
Address of work
location
_ The Commonwealth of Massachusetts
_,,,, Department of Industrial Accidents
1 = =ice f I Office of Investigations
r=" allir "� 600 Washington Street
r = Boston, MA 02111
www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LegibIv
Name ( Business /Organization/IndividuaI): VIA* \ 4
Address: 'tb Nt bl j
City /State /Zip: Act blV Phone #:
Are you an employer? Check the appropriate box: Type of project (required): ‘
/
1. I am a employer with 4. fl I am a general contractor and I
have hired the sub- contractors 6. ❑New construction
employees (full and/or part-time).*
2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship anti have. no. enployees These sub - contractors have. g. El Demol on
employees and have workers'
working for me in any capacity. 9. O Building addition
[No workers' comp. insurance comp. .insurance
required] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am- a- homeowner doing-a l -work -0- - have:tyxerc th ar__ _11.- 0- Pltmb_ingrepairs or additions
myself. [No workers' comp. right of exemption per MGL 121 Roof repairs
insurance required.] t • 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. lithe 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 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. rie advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance' coverage verification
/do here +%. under the pains and penalties of perjug that the information provided above_ is_truemnd_correct._
Signature. rimp- Date: % -ic."iv
Phone #:
: ( O ff i c i a l u s e o n l y. Do not write in this area, to be comp led 9, city or town official
City or Town: Permit/License #__
Issuing Authority (circle one):
I: Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector _ _
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
\-3;0 Name of License Holder : \Apt& CS T 14
License flu ber
1 k'8aX `I VI Va. 01330 4 - 1 to
A Expiration to
41 — b2- C
Signatu Telephone
9—Registered—Home Improvement Gontractor : hr „ Not Applicable ❑
it( aul• c lkti%
Company Nam Regi r tion Number
• lta, ox 1•\ , N‘tisQ MAC O33a S �z
Address ��tt rr Expiratio Dat
Telephone I g lk
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 ❑
otion
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
Employers 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
.__ T..
nrt atnptdn urdmances: a ems_ , • .: • - -. .1 i . oral Annotated.
Homeowner Signature
+ s
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition iN New Signs [D] Decks [C] Siding [0] Other (� ( t l y )
Brief De rip pf PSoposed s C ` � L A �f� S =1 � I `:" M l' 5 vE op *es Work: c t! Ep + lA "� Ed ` u 't 1 A ass. 1
Alteration of existing bedrol Yes _ X No Adding new bedroom Yes X No
Attached Narrative . Renovating unfinished basement Yes % No
Plans Attached Roll - Sheet
sa_7tl eW4i6iise anctbi dsl tialko existing fo mplete=th fol aiii6 :
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
0 161 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
1 r i — V-ANklevl `'`p I / 1/4-443k , as Owner of the subject
property
hereby authorize hAEt‹
to act o my behalf, 'n matter' lati : to •rk a oriz- • sy this building permit application.
Signature of Owner Date C f N `D I II 1, P1NlKf> eel kik0Avki A , as w Authorized
Agent hereby deoOre that the statements and information on the foregoing application are true and accurate, to the besfof my knowledge
and hPlief.
Signed under the pains and penalties of perjury.
Print Nam C / / j
ignature of Owner /Agent C Date R Iv f v
1
& •
•
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 ,
Lot Size
Frontage
Setbacks Front
Side L R: _.. L:
Rear \s`SR
Building Height
Bldg. Square Footage ° °
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
( volume & Location) _ _,
A. Has a Special Permit /Variance /Finding ver been issued for /on the site?
NO 0 DONT KNOW YES
IF YES, date issued:•:
IF YES: Was the permit recorded at the Regi ry of Deeds?
NO Q DONT KNOW YES
IF YES: enter Book Pag and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO er DONT KNOW 0 YES
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 ec NO l
IF YES, describe size, type and location: t'
3 Lx `'(� al?eunr0 S ta x N .... __ ;.
`m D: - A? tfe - an - ro osed ehan es o or a rtions of ns me i ed fog tl`i`e 'Property ? YES 0 NO O
YP P g g •
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, ex tion, 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.
• f
City of Northampton
Building Department Cui�aDr�a+er€t�t ,�f 4"
212 Main Street SerlS� tit
SE? 1 3 2010 Room 100
MA 01060 va
phone Fax 413- 587 -1272 9t .S P,
{)' pegr Az H, xF
' 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:
1-4.)1 C` t �/�
� Map A Lot r 5 Unit
Zone' Overlay District
Eim District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
S '1if t-t t lS , fl
Name (Print) Current Malin gddre �
"i`` 02.1'
Telephone
Signature
2.2 Authorized Agent:
tAft(k 1.0;"0.01 Lk c\44 kiA. G13
Name (Print) Current Mailing Address:
4 1'k (3 1)919
Signature Telephone
SECTION 1- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building is 9t T �*1 5 (a) Building Permit Fee
2. Electrical w LC! f (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number 4115g / 0
This Section For Official'USe Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0215
APPLICANT /CONTACT PERSON MARK LANDY
ADDRESS/PHONE P 0 BOX 61 ASHFIELD (413) 625 -6999 0
PROPERTY LOCATION 37 CHAPEL ST
MAP 38A PARCEL 015 001 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
Fee Paid r/ , u J ' tf b
Typeof Construction: REPAIR SLATE ROOF,FLASHING,SOFFITS,CHIMNEY & STEAPLE REPAIRS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 077431
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INATION PRESENTED:
App roved 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
V ii/ ra
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.
37 CHAPEL ST BP-2011-0215
GIS #: 01' ', COMMONWEALTH OF MASSACHUSETTS
n r:BI,pck: 38A - 015 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE: ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP-2011-0215
Project # JS- 2011- 000375
Est. Cost: $26475.00
Fee: $158.40 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANDY 077431
Lot Size(sq. ft.): 4007.52 Owner: RESURRECTION LIFE INTERNATIONAL MINISTRIES
Zoning: URB(100)/ Applicant: MARK LANDY
AT: 37 CHAPEL ST
Applicant Address: Phone: Insurance:
P 0 BOX 61 (413) 625 -6999 0
ASHFI ELDMA01330 -0061 ISSUED ON:9/13/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR SLATE
ROOF,FLASHING,SOFFITS,CHIMNEY & STEAPLE REPAIRS
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 9/13/2010 0:00:00 $158.40
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner