23A-022 (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 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
permits 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
1, 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
g =' -311 : M Office of Investigations
j �e y 600 Washington Street
_.:_ r Boston, MA 02111 •
-- www.mass.gov/dia
- Workers' Compensation Insurance Affidavit Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Indivichial): S5e M [
Address: 40 CI.. k _t _
City /State/Zip: 'O. c Ali, l`2I Eb ij. Phone. #: 1 l 3^ . ( O
Are you an employer? Check the appropriate box: Type of project (required): .
1. 0 I am a employer with 4. D I am a general contractor and I 6. 0 New construction
employees (full and/or part- time).* have hired the soli - contractors
2 "I am a sole proprietor or partner- listed on the attached sheet. 7. Remodelin
ship arid. have. no enloyees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and_have workers'
insurance. .. 9• D Butldmg addition
[No workers' comp. insurance comp•
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers havexercised their . 11.0 Plumbing 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 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.
I Homeowners who submit this affidavit indicating they are doing all work and them 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 of MGL c. 152 can Iead 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: Be advised that a copy of this statement may be forwarded to the ()M of
Invest - matrons of the DIA. for insurance coverage verification
I do h ereby certify and -if-I ' , enalties of perjury that the information provided-above is_true_andcorr"ect -- ___
S e Date: o / / 0
Phone #: x- (13 3 �';' or '1 O . oZ .
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. PIumbing Inspector
6.Other r- .
Contact Person: Phone #:
or
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: M Not Applicable ❑
Name of License Holder :
License Number
0 Oct k 31-, r c:-IC t O 1 vb L- / - / - /1
Address Expiration Date
+ I' . nat . - Telephone
9. Registered Home improvement Contractor: Not Applicable ❑
55 � /110-141 /3119711
Company Name Registration Number
L k CL I4C ip
Address �r,� �,/ ��j Expiration Date
jor -At s i"7• 0 t 0 -Z Telephone 09� C� t ��`
•�� c"
...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. ^ 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. 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 applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other
Brief Derription of Propost � i
Work: K CI.C.e._ S a. n4 elck), .5j "� sc-fr c ooi - i
Alteration of existing bedroom Yes f Adding new bedroom Yes o —
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
ea. If New house and or addition to existing housing, complete the following:
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
C c< `2 `Ca , as Owner of the subject
property
hereby authorize tS5( ,y_ a'r
to act on my behalf, in all matters relative to work horized building permit application.
t f ., -- 7/6 o /0
Signature of Owner Date
1, J 'j C L 7 1 PL C , as Owner /Authorized
Agent hereby declare that the state ?dents andinformation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Jest - cf)
Print Name
�'+!+�'� Date
sic
»
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
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 ver been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued :.
�F YES: _Was_the-perm.it r gistr-y__of Deeds? — —
NO 0 DONT KNOW 0 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 Q Obtained Q ,Date Issued:
C. Do any signs exist on the property? YES 0 NO
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, exca , 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.
. 4 As
Op�rl only
City of Northampton S tatus of Permit:
Building Department Curb C y P� .n .
212 Main Street e
Room 100 W� r1Wefl Avaii ility 3
Northampton, MA 01060 two S ' is ttf S truct u ral Pl ans
2 ` � h one 4 -5$7 - 1240 Fax 413- 587 -1272 Plot/St a ns
‘\\.\\... Other S pecify
APPLICATION TO CONSTRUCT, ALTER, REP AIR, RENOVATE OR DEMOLIS A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
O''/ c � IIL 4
Zone Map Lot Unit
�� Or t �C ! l .4
0 3 Overlay District
Elm St Di strict CB District
K S
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
2,1 Owner
Name (Print) Current Mailin Address:
,cts /114
j ! o�- Telephone
Signature
2.2 Authorized Agent:
Name (Print) Curr ent Mailing Address:
,� r Telephone
SECTION 3 ESTIMAT CONSTRUCTION COSTS
Item Estimated Cost (D ollars) to be Off Use Only
Construction from (6)
3. Plumbing Building Permit
4. Me chanical (HVAC)
5. Fire Pro tection r / ��7 � � /' / p�
6. Tota = (1 +2+34.-+
5) V � (L X Check Number V
This Section For O fficial Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector
o f Bu ildings Date
File # BP- 2011 -0051
APPLICANT /CONTACT PERSON JESSE MONTGOMERY
ADDRESS/PHONE P 0 BOX 329 LEEDS (413) 585 -8482
PROPERTY LC/CATION 21 PARK ST
MAP 23A PARCEL 022 001 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 ° O
Typeof Construction: REPLACE PORCH FOOTING & FLOOR SYSTEM (SAME FOOTPRINT)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 077410
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOJMATION PRESENTED:
i pproved 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
“-,S1 - 7/2.11 lb
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.
•
21 PARK ST 4 = BP- 2011 -0051
GIS #: COMMONWEALTH OF MASSACHUSETTS
JVIapBlock: 23A - 022 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 -0051
Project # JS -2011- 000098
Est. Cost: $10600.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JESSE MONTGOMERY 077410
Lot Size(sq. ft.): 10802.88 Owner: PLATT CONSTANCE A
Zoning: URB(100)/ Applicant: JESSE MONTGOMERY
AT: 21 PARK ST
Applicant Address: Phone: Insurance:
P 0 BOX 329 (413) 585 -8482
LEEDSMA01053 ISSUED ON:7/22/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE PORCH FOOTING & FLOOR
SYSTEM (SAME FOOTPRINT)
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 7/22/2010 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo