23A-141 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
secu these inspe ctions can result in failure to obtain a certificate of occupan'
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
P
s 4 ..... `. 1' -
The Commonwealth of Massachusetts
Ph Department of Industrial Accidents -
- ►.. l
;77 Office of Investigations '
11 - 1 . =ssi= a 600 Washington Street
• t° Z Boston, MA 02111 -
www mass gov /daa .
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /ElectriciansfPlumbers
Applicant Information ,--- Please Print Legibly
r
Name ( Business /Organization/Indiv 1 J (. i c Vt / 1 ' i CA L'
- - Address: ( 5 L� ,- f l S -f-- Co• - r ec ;
City /State/Zap: / , ( � ' 0, ) Z ,`�'
Are you an employer? Check the appropriate box: •Type of project (required): /
1. ❑ I am a employer with 4.. 0 I am a general contractor and I
6. ❑ New construction
employees (fall and/or part-time).* have hired the sub- contractors
2 dui a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling
ship and have. n7. employees These sub- contractors have 8. 0 Demoiiton
working for at any em)loyees a workers'
bng y capacity. Q
9. Buil on additi
GoII7p, meta -a�P_# _.:.
[No workers' eomp. insurance
required.] - 10. 5. 0 We are a corporation and its ❑ Electrical repairs or additions
i
h
ffi
ocers avexercsed their • 11. Plumbing r
3.0 I am a homeowner doing all work ❑ ?ng epairs or additions .
myself ' co right of exemption per MGL
Ys [No workers comp. 12.Q.Roofrepairs
insurance required.] t • c. 152, § 1(4), and we have no
employees: [No workers' 13.0 Other
comp. insurance required.] •
'Any applicant that cheks box #1 must 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 outside contractors must submit a new affidavit indicating 9irh
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
1 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-Ms. Lic. #: Expiration Date:
Job Site Address: City /State/Zip: • .
Attach a copy of the workers' compensation policy declaration page the policy number and expiration date).
Failure to secure coverage, as requited Mide'r.Section 25A ofMGL c 152 can lead to theiri osition'of criminal penalties of a
tine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORKO.RDER and a firer.
of up to 5250.00 a day against the violator Be advised that a copy of this statement may be forwarded to the Office of
Investiiitions of the DIA for insuirance coverage verification. .. _... _` .. __ .,:
I do hereby certify under the pains -and penalties of perjury that the infornratYon provi+ied.above rsi
Signature: Dat - . . ,
Phone #: '
Official use only. Do not write fri this area, to be completed by city or town ofcied
City or Town: - Permit/License # '
Issuing Authority (circle one):
. I. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical,Inspector 5. Plumbing Inspector
6. Other rt .
Contact Person: Phone #: .
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: ,� Not Applicable 0
Name of License Holder : ` C � 4 3 \ C , � � I C r 1 I k Lk 7 3
License b er
l i
Addrese Alr Date
Signature Telephone
., -- 1 Not Applicable licable ❑
�.1�BL1 11�t' �> �{ I?r ttil��lnlpt 'l)'Y @1t18r1��.Q11�rSIG`�dr',� � �.._....,R�z �x�.,�.�v� <m
I I 3 1/4 4b
Company Name Registratio Number
o
Address Expiration ate
Telephone
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L, c. 152, § 25C(61)
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 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 ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [0 Siding [D] Other [0]
Brief Description of Proposed 2
Work: .,CI 0 ;� 1 C- /1 fkvf ,1 +.z�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a.' IfNew hoes ,and r d i `on to ex t i c> oustnq, comDf`etee th II win
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 la - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 6--e r k ) A') ( /1C- Owner o the subject
property
ebhize „MAN kC ] {� So
to her act y n aut my or behal in al relati ork authorized by this building permit application.
gnaturt; of Ow er ✓ Date
` O ( N DICK (N 60 ),) , as Own /Authorize
tr hereby declare that the statements and information on the foregoing application are true and accurate, to the best o owledge
lief .
\ Signed under the pains and penalties of perjury.
Print Name
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
Building Department
Lot Size 1 t 1 ?
Frontage I i
Setbacks Front j
Side L: 1 R: L:( R: _ 1
Rear
1
Building Height 3
Bldg. Square Footage = i 1 % = = ! k
I
Open Space Footage %
(Lot area minus bldg & paved r 1 d i y
parking)
# of Parking Spaces i --
Fill: � . , .. � Po
(volume & Location) I '- 1
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 9 DONT KNOW 0 YES 0
IF YES, irate issued:(
IF YES: Was the permit recorded at the Registry of Deeds?
NO 9 DONT KNOW 0 YES 0
l r IF YES: enter Book € Pag e. ! and /or Document # :
B. Does the site contain a brook, body of water or wetlands? NO lei DONT KNOW 0 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 9 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 Q NO a
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.
° m ,
City of Northampton u4
Building Department
212 Main Street s , e _ „ .�
Room 100 ate;
Northampton, MA 01060 slrf
phone 413 - 587 -1240 Fax 413- 587 -1272
APPLICATION 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 completed by office
// /
1 n � > ' Map ,q � Lot � .'` � � . Unit
Zone Overlay District
Efrn St. District CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
(
l r )/ r e ,�--
Name (Print) ( Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed j y permit applicant
1. Building L < CI) (a) Building Permit Fee
2. Electrical 1 (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) Check Number
�^ / This Section For Official Use Only
Building Permit Number: 8 � f' l `� l �� I 1S l -/
p
Signature ,
Building Commissioner /Inspector of Buildings Date
111 PINE ST BP- 2011 -0108
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A - 141 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 -0108
Project # JS- 2011- 000191
Est. Cost: $0.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 15725.16 Owner: RAINVILLE LINDA J
Zoning: URB(100)/ Applicant: RAINVILLE LINDA J
AT: 111 PINE ST
Applicant Address: Phone: Insurance:
FLORENCEMA01062 ISSUED ON: " I L -1
TO PERFORM THE FOLLOWING WORK: Chimney top rebuilt
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: OP( g: ° -- 1 d Cl 14A
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND RE I1
• i.n t ur: _
Cefificat of Occu a c � s a
FeeType: Date Paid: Amount:
,,4 0010
Building $55.00 :144 t,p►ll •
+il
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck - Building Commissioner