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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 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
• • • •
600 Washington Street
v.71
1=1= Boston, MA 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Indivirinal): gif E2-- eo7,kw
/ &LE pe
Address: 5 Dui HA- w) pro i 441 p)O 73 -
City/StatelZip: Phone.#:
Are you an employer? Check the appropriate box: Type of project (required): "-
1.0 I am a employer with • 0 I am a general contractor and I
6. New construction
have hired the sith-contractors
employees (full ancVor part-time).*
2. I am a sole proprietor or listed on the attached sheet 7. 0 Remodeling
p f partner-
ship and have nn employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. eimloyees and have workers
u Buildmg atditton
_ comp._io.surancel:
[14o workers' comp. insurance
10.0 Electrical repairs or additions
required.] 5. 0 We are a corporation and its
3 0 I am a homeowner doing all work officers havef.xercised 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
eimployees. [No workers' 13.11 Other
comp. insurance required.]
*Any applicant That checks box #.1 must also fill out the section below showing theirworkers' compensation policy information-
t Homeowners who submit this affidaVit inclicating they are doing all work and then hire outside -contractors must submit a new affidavit indicating such.
i Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether Groot 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 Dia& Sectita'i'25A ofMGL c 152 can lead to the imposition of aiming penalties of a
fine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER. and a fine
of up to $25000 a day against the violator. Be advised that a copy of this statement may be forwarded to the Offi'ce of
Efeitititions of the DIA for insurance coverage _ 1
/ hereby cc., under th and p attics ofpcjicry that the informationprovidetlibove_Lsinmand_con-ect.________
Ay r
4' ze 0 .
Phone Id 13 27 0)4, - •
Official use only. Do not write In this area, to be completed by city or town officio
• City or Tovvra Permit/lAcense # _
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Eiectricaljnspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:.
•
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: / / Not Applicable ❑
Name of License Holder : e411/�? fl r n /4 P. l ' - Z e) ` c 5-
License Number
/Sc a-Gom/I -LLs 0) /Z //z
Address Eviration Date
SOVTM4m PTvw O'14 0)a 3
Signature Telephone
O 4 /13 52-7 01‘. y •
S :i - e te" a, , . em` " ro, .' r t C ,. ,2 -, Q . ah e ;,5 , ,1217_,, Not Applicable ❑
//in G o )T fo,eS 13 710 f 3
Company Name L Registration Number
iss - /.. 1 1)10If l ei )z /)fJ1z
Address /��. �,y� Expiration ate
v SO Pl i 4 PIA- 010 7 3 Telephone tl/33L
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 Up No ❑
IJ V A to l t u ?I� a e 11i1 Amon
The current exemption for "homeowners" was extended to include Owner occupied Dwellines 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing [J
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [❑ Siding [D] Other
Brief Description of Proposed, , ,p�� `�,� E%/$ I�� Fitt APT ST4i/�S
Work: ((�� /� /lam
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes ,C No
Plans Attached Roll (heet
6a Ct a tbiii a air a + a ai Xlara Oi IQ ; `i l it :fOiiO" : .
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
4t I , 10 go csszEjL , as Owner of the subject
property / '�1
hereby authorize C; ° W4 40 L
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I E L4.)ket W n1 EL- , 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.
6 4 l i M e 1) /)4 tEL
Print I► , L C/ Q 1/
Signature of Owner /Agen a te
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete iformatio1 Y►
Existing Proposed Required by Zoning r
9 �, / ,e 1 / This column to be' filled in by + "'
/` �ip,/1 E 01 1 1,Y Building Department r
it'l { 11 1 � ' 1 - 4 ' I kuPTI, _ ..._ ...
Lot Size
Frontage 1 I
Setbacks Front 1 4 i
Side L: ' R: -- L:I 1 R:
,
Rear
Building Height
Bldg. Square Footage 1_'___1 I 1 % i
Open Space Footage
(Lot area minus bldg & paved I I ni L... p_„ I 1
parking)
# of Parking Spaces
Fill: I
(volume & Location) I 't I
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW p YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book [ Pagel and /or Document # „Y __ _ _.__^
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 Conservation Commission?
Needs to be obtained 0 Obtained ,Date Issued:
C. Do any signs exist on the property? YES 0 NO AD
IF YES, describe size, type and location: j
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO AO
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
1, City of Northampton 0 ° = ='
1 4" Building Department W - s
2 9 212 Main Street - it,*15'2F-i;
cT�oNS Room 100 . E E r � � , ` 4 .
of au��'N tN oi� orthampton, MA 01060 a e
NOptHAILD1 phone 413 - 587 -1240 Fax 413 - 587 -1272
°fey J
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:
8 (Zi Q � Map Lot Unit
one Overlay District
Elnt:St Dlst . CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
`JO4A 4 10E R DES 5' LEk_. 8 4' /IDLE 57; �Zo, /r�l�
Name (Print) ` Current Mailing Address:
r' ar irc — Telephone (./
Signature / 3 Z sV 30
2.2 Authorized Agent:
r b W-+1 4 1 - . / 5- s Erv,�Le /CO
s a�rr H�1� P�n� �
Name • : nt) / / Current Mailing Address: C) 0 3
0.•:. ` 4/ 1 3 29 L3Y3
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building f7a, SD V. 4)° (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
6. Total= (1 +2 +3 +4 +5) 2 , 7�• 126 ChectcNumber /�` °� �
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP -2011 -1112
APPLICANT /CONTACT PERSON EDWARD P HAMEL
ADDRESS/PHONE 155 Glendale Rd SOUTHAMPTON (413) 527 -0164 ()
PROPERTY LOCATION 8 MIDDLE ST
MAP 23A PARCEL 120 001 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 �/ T �
Fee Paid v'3 3 7"
Typeof Construction: REPLACE FRONT STAIRS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 020695
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF91 MATION PRESENTED:
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
"ft, /IL/6j 6/34(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.
� t
8 841bDLEST BP-2011 -111
C OMMONWEALTH OF MASSACHUSETTS
►: k .23A - l20 CITY OF NORTR1 PION
L PERSON CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
g ; renoyatign BUILDING PERMIT
Permit # BP- 2011 -1 112
Pr. '# ANL 1 i e i ads
Est Cast: $2 00
P ee: $55.0 PERMISSION IS HEREBY GRANTED TO:
t Contractor: . License:
EDWARD P HAMEL: 020695
Lot Size(sq. ft.): 11499,84 Owner: ROESS ,EI O R & NOR iT ICALJNA
AT: 8 MIDDLE ST te r_ _ _
' fr r . .Phone: 4surance�
15 Ie* R d (413) 527 - 0164 t}
SOUTHAMPTONMA01073 LS .A 4N 6/30/20110 :0000
TO PERFORM THE FOLLOWING WORK: REPLACE FRONT STAIRS
POST'' 71.11,s C SO. IS VISIB JE FRAM THE STREET
Inspector of lng Victor of Wiring I1. �V. Building Inspector
Underground: * w Service: Meter: "U. e- st' 61 f(Cti
� r
oo4ngs:
House # Foundation:
x..
Driveway Final:
Final: ` Final:
Rough Frame: ,..
Gas: 'i,}Dartmgut
Fireplace /Chimney:
Rough: Oii: Insulation:
Final: Smoke: Final: 0. 27 i/ • k 57o s
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
+i-4r A44.44•4040
Certificate of Occupancy Signature.
FeeTYpe: ' Date Paid: Annountr
Building !6/34/20110:00:00 $55.00 i h
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587-1272
Hasbrouck - Building Commissioner