38B-091 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
regulations. The inspection 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
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 (e 6trical, plumbing & gas) the
homeowner will be responsible to make sure that th rades hired secure their proper
permits in conjunction to the building permit iss , and that they get their required
inspections. Failure of the individual trades t ecure the permits and inspections as
required can DELAY the project until suc me as the proper permits and inspections are
made
understand the above.
(Home owner /resident' ignature requesting exemption)
I will call to schedule all r; • uired building inspections necessary for the building permit
issued to me.
Date
Address of wor
location
,
The Commonwealth of Massachusetts
-v Department of Industrial Accidents
- ' Office bf Investigations
!`
600 � Washin Street
— Boston, MA 02111
A www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/EIectricians /Plumbers
Applicant Information • Please Print Legibly
Name ( Business /Organization/Individual): M t A(� _tuts _
Address: 1 () ,,) Y-
City / State /Zip: '\ f \C -4 ° Am, 013 Phone #: 4 - t %1
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. n I am a general contractor and I
mployees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction
2. 1:I am a sole proprietor or partner- listed on the attached sheet. 7. [5ir Remodeling
ship and have no employees These sub - contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. D We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
re
3. ❑ I am a homeowner doing all work � P
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. ❑ 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.
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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investioations of the DIA for insurance coverage verification.
I do l • w i;_ , , der the pains and penalties of perjury that the information provided above is true and correct.
Signature: ”"��' Date:
Phone #: 44 ")Z( "' Vi
1 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
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : IA hi� �'"`' CS T T 4; 1
License N m r
addre Expiratio D e
Signatu Telephone
9. Registered" Home Improvement Contra or: _ , " , , . ,,," ,,, %" ,> Not Applicable ❑
k..E\ c;04. "17i... N o 1i_ Sp& v M cia.4
Com any Name Registrat on umber
Address Expirati D e
Telephone *Ai VCA
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 buildin ermit.
Signed Affidavit Attached Yes No ❑
11. - Home Owner Exemption
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. CNIR 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 accesyncirsuch use and/ or farm
structures. A person who constructs more than one home in a two - vear period shall be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to t$e'lJuilding Official, that he /she shall be
J'
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be • . uired 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' Co ..ensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachu •tts 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 res %onsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning La s and State of Massachusetts General Laws Annotated.
Homeowner Signature
/ Q*-
,
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition Z New Signs [D] Decks [C] Siding [D]
Brief II ription of Pkopos d ` �� V ` �W �� 74
Work: , 4, 1( O is c i Ai w% • 4 (AN CC co . . N•3N �`' 'a tl C O S
Alteration of existing bedroom Yes No Add' g new bedroom Yes No /- Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the foi(owinq:
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 ,r'`
i. Is construction within 10 . of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement r cellar floor below finished grade
k. Will building c form 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, \ K° i , as Owner of the subject
property
hereby authorize &P(
to act on m behalf, in all matters lative to w authorized by this building permit application.
c�klr
Signature of Owner Date
1 Vlet(k 1 ar , as +�a�Authorized
Agent ereby declare that the atements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Sign d under the pains and penalties of perjury.
Print me la V`, O
Signature ofer /Agent '
f 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
Lot Size
Frontage
Setbacks Front
Side L:'..__. ,..., R... .._.. L. _ ._ ._ ., R .. __._,.,......w
Rear
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 er been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Reg' ry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page 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
, Date Issued:
C. Do any signs exist on the property? YES (3 NO ei
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, exc ation, 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.
Deartri tent use onty
City of Northampton Stags of Ferrrlt a
Building Department tutb-Ctiti,P1
212 Main Street SewertrA►aabrltty °i
� Room 100 Water etr Ava at rlity
`u � mton, MA 01060 T Sets of Struthral Plans
ph���one 4 p Northa 3 -587 -1 Fax 413- 587 -1272 P &te t'tans
Other Specify
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
L vt0 5 > \ ONA■.? Map Lot Unit
404 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record. f
Name (Print) Current Mailing A d ss:
� .6b cy
• I Telephone
Signature
2.2 Authorized Agent:
4 " 1•1 VWS
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 kf 3 e (a) Building Permit Fee
2. Electrical 6{ (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection /l
6. Total -- (1 + 2 + 3 + 4 + 5) Check Number Yid' 1 (
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
•
File # BP- 2010 -0832
APPLICANT /CONTACT PERSON MARK LANDY
ADDRESS/PHONE P 0 BOX 61 ASHFIELD (413) 625 -6999 0
PROPERTY LOCATION 6 MUNROE ST
MAP 38B PARCEL 091 001 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
Construction: PORCH RE AIR
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 'F'O t7 C tt Kac,,T R E MA `pi $C (.€F_ n/C r
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION 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
3/ � s l 0
Signature of Building Official Date I
g g
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.
6 MUNROE ST BP- 2010 -0832
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B - 091 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- 2010 -0832
Project # JS- 2010- 001230
Est. Cost: $3000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANDY 077431
Lot Size(sq. ft.): 4965.84 Owner: WOFFORD PATRICK W & CATARINA I COSTA - WOFFORD
Zoning: URB(100)/ Applicant: MARK LANDY
ril 6 MUNROE ST
Applicant Address: Phone: Insurance:
P 0 BOX 61 (413) 625 -6999 0
ASHFIELDMA01330 - 0061 ISSUED ON:3/25/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: PORCH REPAIR
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: OR 1- ) 21) (0 LpU I S
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
fe
Certificate of Occupancy 2 l0 /jArtY Signature: f'
FeeType: Date Paid: Amount:
Building 3/25/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo