18D-053 (3) 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
jermits 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
Date
Address of work
location
.. " • ' • , .
The Commonwealth ofMassachusetts
—__ : Department of Industrial Accidents
_ t= . E Office of Investigations
• _..-
9 ... _ 600 Washington Street
=�_ Boston, M4 02111 .;, www.massgov /dim
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): W•ND0W WORLD
56 Dhmock Street
Address: . 01053 , .
�M-$712
City /State/Zip: - Phone. #: .
Are you an employer? Check the appropriate box: Type of project (required): /
1. ❑ I am a lo..er with 4.. 0 I am a general contractor and I
P . Y 6. ❑ New construction
employees (fall and/or part-time).* have hired the soli- contractors
2 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and. have no a loyees These sub - contractors have .8. [] Demolition •
working for me in. any capacity. eiployees. and have workers' 9: Boil a
[ workers' comp-. insurance
r equir ed 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
] -
3. I am a homeowner doing all work officers have Zxercised their 11. ❑ PIumbmg 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 o 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 afdavit:indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
CContractors that check this box must attached an additional street showing the name of the sub- contractors and state whether or not thoseentities have
employees. If the sub - contractors have employees, they must provide them workers' camp. 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 /Stafe/Zip.' -
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
,
Failure to secure coverage. as required tthder Section 2 ofMGL c. 152" can lead - to the imposition` of criminal penalties of a
fine up to S1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator Be advised that a copy of this statement may be forwarded to the Office of
TnvestiQahons' theDIA for insurance coverage ve fica'tion. _ s.. :.
/do hereby certify under thepains and penalties ofperlu ry the informationprovtdee_above irtrue_andcorrect 4.- Si • . - tore: _me tr at e .. ,
Phone - _ tee ' C 7744
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. Eiectrical,Inspector 5. Plumbing Inspector
6.Other e
Contact Person: Phone #:
r 3
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :J A-- `Y ,
License Number
6
Address Expi on Dat
• nature Telephone
t Registered. aiiie.lmprovement:C'ontraetor -'Ma .. , ... ., Not Applicable ❑
17 dz
Company Name Registration Number
WINnOW WORLD 41/ �--
Address 56 Dimock Street Expi tion Date
Leeds, MA 01053 Telephone
S:46-8712
—
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 ❑
11. l wt>li+�i
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 aonlicable)
New House ❑ Addition ❑ ReplacemerRdows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [D Siding [01 Other [0]
Brief Description of Proposed r
Work: > <-3 4' (Li t , t-- S L w%-ei /Svt ✓ —
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a.1f t e 1iou eaind o aidtht on io a ist np . r ismq c ml fete t re fait ivi 1n`ct:
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
, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
S ignature of Owner Date
V._ , as Own�r /Authorized
i,ereby declare that the statements and information on the foregoing application are true and accurate, to the best of'mykntiW'fvedge
a • •elief.
Signed under the pains and penalties of perjury.
Print Name
Signatur- • ' r Thge 1> Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplet.? Information
Existing Proposed Required by 2 oning
This column to b. filled in by
Building Department WO, S t
r
Lot Size 1 _ ._ - -� , r ,� i
ea :3* C s i .'� I
Frontage ` -- - M
Setbacks Front j 1 1
,
Side L: , R _ L:r F R:V F
Rear
____ j r
Building Height
I = '
Bldg. Square Footage r-1 �'
I I f
. Open Space Footage
f
? l i
(Lot area minus bldg & paved ,— ; i 1 ;
parking)
# of Parking Spaces
Fill:
I I 1
(volume & Location) T
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::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book Page 1 and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q 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 0 NO 0
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 Q
IF YES, describe size, type and location:
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
- 4
City of Northampton
RECEIVED Building Department
- 411441
212 Main Street
Room 100
, aak 444A
MAR 2 ■lorthampton, MA 01060
pho e 413-587-1240 Fax 413-587-1272
°EP ow ammo gi-joK, 4
:,:tVirfs);:f f
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be corn feted by office
1.1 Property Address:
7 49/
4-3 Ob Map j kP Unit
11(.-) /9,7
Zone tn ct
403 _
,xze
EMI St District CR District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
___ A ,
, r1)
Name (Print) Current Mailing Address
,s.
Telephone
Signature
2.2 Authorized Agent:
/7-.
Name (Print) Current Mailing Address:
• p1ture Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection , i 3 s --- --
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building CommissioneffinsPector of Buildings Date
80 DAMON RD #4305 • BP-2011-0771
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18D - 053 CITY OF NORTHAMPTON
Lot: -105 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit # BP- 2011 -0771
Project # JS- 2011- 001271
Est. Cost: $2800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN CORBETT 078297
Lot Size(sq. ft.): Owner: SCOTT JILL A
Zoning: GB /GI /SC/WP Applicant: JOHN CORBETT
AT: 80 DAMON RD #4305
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586 - 8712
LEEDSMA01053 ISSUED ON:3/28/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 4 REPLACEMENT WINDOWS &
SLIDING DOOR
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 3/28/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner