22D-017 4
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 t heir own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regiilatinns e inspection proctes &egirres 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
----------- . - - -pe ts - in - conjunction._to_t ' ..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
The Commonwealth of Massachusetts
Department of Industrial Accidents
,:, -1 � Office of Investig,ations
•
,+= 600 Washington Street
if Boston, MA 02111
� www.mass gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information J Please Print Legibly
Name ( Business /Organization/IndividuaI): 4' -.'� � ti) lid 5'42,6 (:)
Address: 7 5) l /v / C
City /State/Zip: I /G,G l AAY/ tc2 r 4/1 4 Phone. #:
Are ou an employer? Check the appropriate box: Type of project (required):
1. I am a employer with I 4. fl I am a general contractor and I 6. New construction
employees (full and/or part-time).* have hired the sub-contactors
listed on the attached sheet. 7.
2. El I am a sole proprietor or partner- ❑ Remodeling
ship and have. no eloyees These sub - contractors have. g- Demolition
for me in any capacity. employees and have workers'
working
Y ap ty 9.1:1Budcling_addition
�
e-
L [No workers' comp. insrrrar ce cem�. ,, ., ,u _ �
required:] 5. E We are a corporation and its 10.0 Electrical repairs or additions
3- 0 I-am a- homeow e a g -all work o cer have xercis llaeir___.-- --1-1.D Plumbing repairs or additions
right of exemption per MGL
myself. [No workers comp. 12.0 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 ouide contractors must submit a new affidavit indicating such.
TContractors 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
formation.
Insurance Company Name: / (7 j iti
/` - '. , 1 7 �' /' 6 l j Expiration Date: -0 -C"
Policy # or Self -ins. Lic. #: ' �/ c-.) ar -" �i :,� / xp
Job Site Address: ! % e Li/ : � City /State/Zip ���'t' � ' /
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 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 Erie
of up to $250.00 a day against the violator. lie 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 penalties of perjury that the information provided _above_i _true_androrrect _.._._ _.
Si gnature: _iJ.. --- . - ,i % Date:
Phone #: v 1 ' 7 dC.
Official use only..Do n write in this area, to be completed by city or town officiaL
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of H ea l th 2. Building Department 3. City/Town Clerk 4- Electrical_ Inspector 5. Plumbing Inspector
6.Other r
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. j / Not Applicable ❑
Name of License Holder : C: IQJL L 2. 4 `0 7
License Number
6A1 fit-., / b A 6 pe,t;
Address Expiration Date
o 0 - 4/4M.g Yes
Signature Telephone
- . -..
Re Not Applicable ❑
9: gistered.t{ame ImproveinentGonfractar, .. ...... ..._ ........ �A ��� � . _ PP
Company Name 50 / / Re r
Address /� )�� Expiration Date
1g2 i �,� 1447 4 ogi T / Telephone , - /g — o1 016 '
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavi must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the builds permit.
Signed Affidavit Attached Yes No ❑
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
o - - r-at::Laws- Annotated.
amp on r finances; 'State
Homeowner Signature
t
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ED Roofing 0
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [❑ Siding [D] Other [D]
Brief Description of Proposed � f
Work:
'r/t -4 f/9// X i) y 1 o / «`cap"'1R)0
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
a If View ti6use'.and°oi- a..dcli# ion io existir q, hou sinccomtiiete the-foifiawir c :
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, Qjs '" ` 0 /' , as Owner of the subject
property ,q
hereby authorize dci'i t.) i fl L. /3 A. /
to a on my b half, in all matters relive to work authorized by this building permit application. •
� � � L � .Il. ,• l f� /ri �'��.:�
Signature of Owner •e _ _ Date ?
I, G' 44_0 i N L. 8 21 1 , as Ovrnw (Authorized
Agent hereby declare that the statements and informa on on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Ei2. G: A3 L r (2 d )
Prm1 kame /,. _ s r
Signature of OrseatlAgent Date
r
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 i
Side L:— _2 R: __...... L: _ m..+ R _.. ..
Rear _ .. ....
Building Height "`
Bldg. Square Footage l� _ % r 7
Open Space Footage _,.
(Lot area minus bldg & paved _, _
parking)
# 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
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book 1 Page= ? and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
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:
- 07 tfiere any prcif: Zc tinges to or a roots o signsmtenae for t1 property ? YES 0 NO 0
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 Permit from the DPW is required.
• ,. _ �s�enl
City of Northampton Stasof
� i� r
Building Department
SEP 2 5 2009 2212 Main Street a
Room 1 00
Northatrlpton, MA 01060uwe
phonet�41 -587, -1240 Fax 413- 587 -1272 � I a n'
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: {�
7t; e / ) 1`'.0}94 Map Lot Unit
/i7 /s;, S N C.. Z Overlay District
EIrn St s District' CB District
.SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
- -- - - - - --
2.1 Owner of Record:
Na 7e (Print Cu qt Mailing % dregs:
1_ Lr9Lai4. Telephone ;
Signature C ( 1 '
2.2 Authorized Agent: nn J �
E1 it), to L 'J f 75/ igg I tie., / 0 7'+�frn�7� �
Name (Print) Current Mailing Aess:
�5ignature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building c r/ o° (a) Building Permit Fee
1 _ _
2. Electrical (b) Estimated -Total Cost of
Construction from (6)
3. Plumbing Building Per Fee
4. Mechanical (HVAC)
5. Fire Protection
6 Total = (1 + 2 + 3 + 4 + 5) fU4 Check Number /6
• This Section Far Official Use Only
Date
Building Permit Number. Issued:
Signature:
BurRding Commissionernnspector of Baildmgs :...,, - • Date
BP- 2010 -0330
GIS #: COMMONWEALTH OF MASSACHUSETTS
Wit: 22D -017 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 -0330
Project # JS- 2010 - 000452
Est. Cost: $14700.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R SIDING 026846
Lot Size(sq. ft.): 2134.44 Owner: GAGNON THOMAS H
Zoning: URA(100) //WSP Applicant: B & R SIDING
AT: 175 RYAN RD
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586 -4167 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:9/29/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL VINYL SIDING
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 9/29/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo