38B-284 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 (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
iermits 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
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.
Date
Address of work
location
7
n - ,
The Commonwealth of Massachusetts
Department of Industrial Accidents
—T Office of Investigations
t _: :416-
= _ 600 Washington Street
Z Boston, MA 02111
www.mass.gov/dia •
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers
Applicant Information Please Print Leribly
Name ( Business /Organization/Indivirdnal): i - 41.124 ��
Address: 3 f /G 4�
City /State/Zip: , 4 01 Phone#: 31 7 l' 6r'7‘
Are you an employer? Check the appropriate box: Type of project (required): /
1.O I am a employer with 4. 0 I am a general contractor and I 6. 0 New construction
employees (full and/or part- time).* have hired the sub- contractors
2. ] a a-sole proprietor or partner- listed on the attached sheet 7. Remodeling
ship' and have no a loyees These sub - contractors have 8. E Demolition
working for me in any capacity. employes and have workers' 9 Q ding addi on
[ workers' comp. insurance comp.insr**anr•e f -
- - -- -.-- -_
5. 0 We are a corporation and its 10.[] Electrical repairs or additions
required.] ocers ave- their . 11. Plumb 3. 0 ] I am a homeowner doing all work officers have h 0 repairs or additions
myself [No workers' comp. nit of exemption per MGL 12.0 Roof repairs
insurance required:] t ' c. 152, § 1(4), and we have no
[l`T
employees. o workers' 13.[] Other
- • comp. insurance requited.].
* Any applicant that checks box #1 must also fill out the section below showing thei workers'- corrrpaisation policy information: .
t Homeowners who subnrit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that r},Mtr this box must attached an additional sheet showing the name of the subcontractors and state whether ornot 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 eaptration date).
Failure to secure coverage, as required under Section ofl�%IGL`c: 152 can Lead to the iiiipbsitiori of criminal penalties of a
fine up to $1500.00 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 Be advised that a copy of thiis statement maybe forwarded to the Office of
Iiirestigatlons of the DIA for insurance coverage verification , _ _ , , _ _
_ I do hereby certify der the pains and penalties o , erjuiy that the information provided.above.rslrue_and_corre _ . . _
Signature: /7 -� , c ' . Date; .
Phone #:
Official use only. Do not write in this area, to be completed by city or town official
City or Tovvn: 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 #:
It
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su • • rv'sor: — Not Applicable ❑
FAV Name of License Holder : -P ` - g1f
License Number
i i____ ,, /- 5 --. r
A. .ress Expiration Date
Aoxyleption 5 —d / .____ a l/ --do-4p_
Signature
`.f• —
3 'R red-Katria 6;1. maim into +..7W orx .; � 4 , .2 Y C,V .z >.._. Not Applicable ❑
V ' �
. e9; r/ r/ /, -1
Com • an Na , = Registration Number
Address Expiration Date
■ 1 Ur ,,�► E ' Telephone 31--(-617J`
S => ION 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 ❑
a
1 :H wne
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 buildine 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
t
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition El New Signs [0] Decks [C] Siding [0] Other [D]
Brief Description of Proposed / ' • ) 1
Work: -I /Lv ` -.di <<r
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. iti eidhii3 = iii irid It o N a ' fq ,f iffi c n at l t ilitiBMiia:
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, i / , as Owner of the subject
property _
hereby authorize /' to act on + y behalf, in vie,--e--,..--,-7/4:1-2
e r- • lative to work tho this building permit application.
I, _,.A/Li tdi —
Signatu' • ner Date
1, ,. e E—ri:.
, as Owner /Authorized
Agent hereby di that the statemen s and ation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of pe ' • . --_
Print Na e
Signature . Own /Agent Date
r
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information ,
Existing Proposed Required by. Zoning r
This column to be filled in by jr
Building Department F
Lot Size f �..... __.,._. _. . /
w
Frontage
Setbacks Front 1 t r I
Side L:l 1 R:__ a L:! , R:' ` ?
1 1
Rear f
Building Height
Bldg. Square Footage I'"""'" -i '-j % I 1 i
Open Space Footage % I
(Lot area minus bldg & paved i „_,,,_„_ :„ J _.. -._ro?
parking) -
j
# of Parking Spaces _-
Fill: ;
i "
(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: f 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book f f Pag and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES Q
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 Q NO i
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 0
IF YES, describe size, type and location: s
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
J
�, = City of Northampton , , .,. - � y
�G Building Department :1 � 4 ` �'
212 Main Street g ° _ :
�� Room 100 E
\ ► : hampton, MA 01060 - , s
oF�0oN a ■
413 - 587 -1240 Fax 413 - 587 -1272 , - = �
s
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: w !
P / �� _Map Lot .Unit
-- 7 - ,
e Zone � Overlay District
./
, i .").-J
Elm St: Dist CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: ��
Name (Pri Current Mailing Address:
Telephone
Signature
2.2 Aut ' on ed Agent:
Name (Pnn 1 Current Mailing Address:
1,
Signatu Telephone
SECTI •' S ESTIMATED CONSTRUCTION COSTS
Item Est imated Cost (Dollars) to be Official Use Only
,. pleted by permit applican
1. Building i1 a () (a) Building Permit Fee
2. Electrical (b) d' Cost
1 -----
Construction EstimateTotal from (6) of
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection _
6. Total = (1 + 2 + 3 + 4 + 5) Check Number � Lid- S
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Date
Building Commissioner /lnspectorof Buildings
270 SOUTH ST BP-2012-0109
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B - 284 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP- 2012 -0109
Project # JS- 2012- 000165
Est. Cost: $10000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES ROBERTS 99404
Lot Size(sq. ft.): 9931.68 Owner: COCCO JOHN J & CATHERINE M
Zoning: URB(100)/ Applicant: JAMES ROBERTS
AT: 270 SOUTH ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527 -6078
W ESTHAM PTO N MA01027 ISSUED ON: 7/29/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 7/29/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner