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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 hone owner exemption, 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 occunancv
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
i ermits 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.
e owner /resident's signature requ • ng exemption)
I will call to schedule all required build' . _ inspections necessary for the building permit
issued to
Date
Address of wo
location
,
7
a. t .
. .
. .\ The Commonwealth ofMassachuse
Department of Industrial ACcidents
Office of InVestigationS
600 Washington Street
11 111= --- / Boston, MA 02111 : • . .
-.=..-:-
www.mass.gov/dia , • '
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
7 Applicant Information - Please Print LeRiblv • ::',: .
Name (Businesi/Organiiation/IndiviOng1): ,
• •
• ! •
• . Address: ,. • -
City/State/Zip: - . Phone.#: • -
. .
Are you an employer? Check the appropriatebox: • Type of project (required): "
• 1.0 I am a employer with 4.. 0 I am a general contractor and I '
6. 0 New construction
have hired the sub-contractors
employees (full ancVor part-time).
•
2 ,KTI I aril a Sole proprietor or partner-
lister' on the:attached sheet: 7. 0 RemOdeling
''.ndh
These sub-contractors have .8. 0 DeMolition . . • .
. . ave no employees
•
working forme m any capacity . emk workers' 1 -9.: Er-B-f .
rige wOrkeirs" comp-. insurance
10.0-Electrical repairs or additions , . . 5. 0 We are a corpoi tion and its
3. 0 I am a homeowner doing all work officers lia•VetcerCisei their 11.0 Plumbing repairs or additions
myself [No workers' comp. • deg Of exemption per MGL r-7 . .
12.11 Roof repairs . •
' • insurance rewired.] t • • , . 152, § 1(4), and we have no • .
einployees. [No workers' 1 4- 0 6 ther r • '
. - • . • Comp insurance reqUired.j. . . • - - : .
*My applicant-that checks box #I must also fill out the section below showing theirieorkets' compensation policy informatitht
t Homeownern who submit thii affick:vitincriciaiin' i they are doing all wait and then hire outside coati-tors =at submit a new affidavit indicating such.
:contractors that check this box must attached an additional sheet showing the name of the suh-contractors and state whether or notthase entities have . •
employees. If the sub-contraCtorshaVe cmployeet, they mustprovide their wOrkets' comp. policy number.
, 1 run an employer that is providing workers' compensation insurance for my einplOyees. Below is the policyandjob site
information. .
I insurance Company Isame: Q ‘-)(' _-: ;,1 - R.. i') (
• - 1 Lic
or Se
PO
licy # lf-ms . #: ‘r-. — S`LS f- 3 .:._., 1.r") , ` 1-(-. --) t i Expiration Date: - 1 ')..(/ i /
. .( . (- t
Job Site Address : ( -j( '' :r , 'S '
., _ 1 ')-( . e ''.-- ON . City/State/ZiP:' . \ .. ,':-_, •:-> - •
Attach a copy of the worker?' compensation pokey declaration page the polic-y nurober and date).
. . . .
Failure to secure coverage as regaled iiticir S6ttrOh 152 can lead to the iiiii5Oiiii6ii Of'Ziniiiiiii:41es of a
fine lip to S1,500.00 and/or one-year imprisonmen4 as well as civil penalties in the form of a STOP WORK-QRDER and a fine
of up to S250.00 a day against dieViolatcir. Be adviSecl that a copyOf this statement maybe fO o rwarded to the:OfriCeiof :_;
- ave -- s a tiialioOf thi'DIA — foi l iiiiti e'Ciiiiii t _ ---T ' 7:_ _.:"„ l :,`,..
\
firo7iiiii_fty1eii-if:fifii ii4.; ti i p '3 T ;iii;LOe;ii ,11 ; :iitai ii;i:firirriliin;r;i;ilirii0
,,:./ ,,,
- ,.. .
Si tare: 7:.)., -....! ./. . --.' i - • • ate- ..: / • . . . ,
. .
Phone 4: ';Th, C.,-:- C 4- (0 c7... . - s. ' . . . - - • • .
. - OffiCial use only. Do not write in this area, to be completed by city Or to wnOfficitil
. .
City or Town: • "- Permit/License # '
I Authority (circle one):
.. .
.1. Beard of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector
1
6. Other
.
Contact Person:
Phone #:
- •
r
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: \ Not Applicable ❑
Name of License Holder : > "''� `� ` V. \\ 1 "' " ` ( 4 (0 lb
License Numbe
Address Expiration Date
// el
Sicfnature Telephone
9:`Rectlstere ll.Ffntnr Irttprovemen ' Gain racttor� yi a r ,�' 77, :zezittga Not Applicable ❑
\fin. a' ,� > ;r ;� \ C g� ` ;-
Company Name Registration Nu ber
9 (
Address Expiration Date
'04 - ' k ° <? Cw(('71c -� 'a Telephone 1
—
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. ... ❑
The current exemption for "homeowners" was extende o include Owner - occupied Dwellings of one (1) 0 0(2) families
and to allow such homeowner to engage an individual for ' e who does not possess a license, provided t t the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.
Definition of Homeowner: Person (s) who own a parcel of lan • on which he /she resides or inte • to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or ' • ached structures access. • to such use and/ or farm
structures. A person who constructs more than one home in a two ear period sh of be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acce.table • e 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 be req ' ed 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 (W• ers' Compensation) and ■ apter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of Massachusetts General Laws An .fated, you may be liable for person(s)
you hire to perform work for you under this - rmit.
The undersigned "homeowner" certifie . nd assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State . • ocal Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
1
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing IR
Or Doors 0
Accesso Bldg. r De olition ❑ New Signs [0] Decks [p Siding [0] Other [0]
�fDes
Bricripti n fProp c osed, r . r . `—�, r y T �� I �•C_� �p\.r.i Si \I, `.'�.,i �kk( -.
work: 11 � .,.. , 1c ...1°, 1', Q\+�, - s r\,---j 1 1 v ..( 1 0 \' ;� � l , 'ril>> S 3 i _� �
. 'C Q,riNN 9 i'N .. 3'.:
c
Alteration of existing bedroom Yes )�' No Adding new bedroom Yes Y No
;
Attached Narrative Renovating unfinished basement Yes )G No
Plans Attached Roll - Sheet
sa. tite , to ilid*r dtl I t rti rcrii iir a cr eili a tatiga:
a. Use of building : One Family Two Family Other
b. Number of rooms in e- • family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new constru i• • aimensions
e. Number of stories?
f. Method of heating? i = •laces or Woodstoves Number of each
g. Energy Conservation Compliance. Masschec nergy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. • , etlands? Yes No. Is construction withi 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-- `� 1 as Owner of the subject
C ' '' ) C, bft , ) CV\ N S . (;\ \\
property
hereby authorize
to act on my behalf, in all ma f ers relit to worjs aythori by this uilding permit appli tion./
Signature ofi Owner / Date (
I,
c--`-')W, 1 c, f 1 '�.\,;, l , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains,and penalties of perjury.
Print Name „..'"/ 7, ./
7' - > Y4f - A ' .- - -/ - P/ ".' /V
Signature of Owner /Agent 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 3
Building Del lartment +�
—"' m
Lot Size .\ ' _ _ l
Frontage 1 i 3
Setbacks Front \(----1
Side L: ` R: — 1 L.1 a R:? I
t i x 1
Rear 1
Building Height , i [_ _ r ,
Bldg. Square Footage 1 I 1 l % I Lili""
Open Space Footage 0 0
1- 7
(Lot area minus bldg & paved L.....
parking)
# of Parking Spaces -
Fill: __/ ,____ ___ ,�. . . _
(volume & Location) 1
r
A. Has a Special Permit /Variance /Finding ever bee ' issued for /on the site?
NO 0 DONT KNOW 0 \ ES 0
2
IF YES, date issued:; 1
IF YES: Was the permit recorded at the Registry of Deeds.
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book Page i and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conserv. ion Commission?
Needs to be obtained 0 Obtained , Dat Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0
IF YES, describe size, type and location: 1 ,
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 ,,,.,.....- q , ,,, , 47,- - 1,..,_ ",,,,0 ,.-_ , 4,0 Ac s.,:,,P,,-„,,,q,,,:„.v-,Ti, ' '-'"
\ : -::: ‘.-, rrk l igi ; .W', 44 4.41. si.4. .''. '1 ' 4 - ',Na' 0 1 , iv: . - -
City of Northampton .... .11i-actiku,t:44,
, cov
‘--‘ Building Department
AA04
212 Main Street
''' °.:,t4faaVW,,t1,f,atr.”44:fgs.'Atitk Pia
st rION Room 100 ''
o ampton, MA 01060
,15'.:431:a'iit-An!f4,71,!;'-u-:-, ',.:',,°t45P1F45*,7r7,7azni.:4,0,t'nf
- - --- : 15f : . :7-1240 Fax 413-587-1272
:. !CATION 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 comPieted by office
6 Cr'c1/4 dc 31' Map Lot Unit
Zone ' - - OverlaYDIstrict
Erni St. DistOct ' CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
e --.. -----. \
73 (----) (..._).‘ kl
.
,
i
Name (Print) j Current Mailing Address:
'I
Telephone
Sighature
2.2 Authorized Aaent:
:„...... c?
,,,, k
V
Name (Print) / 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 1 Itt)
' (a) Building Permit Fee
2. Electrical C' '% k.) (b) b ) E C s o ( i n n ; t u e ct d i o tfarol Cost from (6) of
• 3. Plumbing f ift%Itaii IL`•4 ' - '
Building Permit Fee
t
t I
4. Mechanical (HVAC)
5. Fire Protection 06V2
6. Total=(1+2+3+4+5) 2,7_,O o () Check Number /
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File # BP- 2011 -10153
APPLICANT /CONTACT PERSON HARLOW BUILDERS
ADDRESS/PHONE 336 COLES MEADOW RD NORTHAMPTON (413) 586 -0465
PROPERTY LOCATION 67 PARK ST
MAP 23A PARCEL 031 001 ZONE GB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out /`y *3A
Fee Paid /09
Typeof Construction: STRIP & SHINGLE ROOF,REPAIR FOUNDATION,REPLACE.
LANDING /STAIRS,REPAIR SILL,FRAME DOORWAY —° 1 &asr 5 # ( 1,4 ION £X(ST I NG F 001 ; R I N t
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 052460
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
i../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
(. L 7, L/LJ 6 717/1
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.
67 PARK ST BP- 2011 -1063
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A - 031 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2011 -1063
Project # JS- 2011- 001713
Est. Cost: $22000.00
Fee: $132.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HARLOW BUILDERS 052460
Lot Size(sq. ft.): 17293.32 Owner: HARLOW SCOTT
Zoning: GB(100)/ Applicant: HARLOW BUILDERS
AT: 67 PARK ST
Applicant Address: Phone: Insurance:
336 COLES MEADOW RD (413) 586 -0465 Workers
Compensation
NORTHAMPTONMAO1060 ISSUED ON:6/17/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF,REPAIR
FOUNDATION,REPLACE LANDING /STAIRS,REPAIR SILL,FRAME DOORWAY - MUST STAY
WITHIN EXISTING 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:
6° 7/P 073d-
FeeType: D t o Paid: Amount:
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner