23A-160 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 fandly
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
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 me.
Date
Address of work
location
,
. .
• .,
The Commonwealth of Massachusetts
Department of Industrial Accidents
,5, 11 ■9:4111: ,i' Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers .-
Applicant Information Please Print Legibly
Name (Business/Organization/Individnsi): 0., o /4 t
_ -... A ..........41
Address: . _. 1 ..... A . A A 0 , ..." . IL . a ii. , 4t LI A 0/06 c
City/State/Zip: j ..,6,- ) ICC. Phone.#: -S — 33 S_
Are you an employer? Check the appropriate box: Type of project (required): 11
• 1. CI 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 and/or part-time).*
listed a.
2.1E4 I am a sole proprietor or partner-- • on the ttached sheet 7 0 Remodeling
• These sub-contractors have
. ".. and have no Th b
loyees 8. 0 Demolition
enalaloyees have workers'
working for me m any capacity. 9 0 Building addition
No- wadcers' comp-. insurance
required] - 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. 0 I am a homeowne; doing all work officers haveixercised their . 11.1 Plumbing repairs or additions
myself [No workers' comp. right Of exemption per MGL 12. rn
Li /coot reparrs I.
insurance required.] t ' c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other ee 0 i
, ‘ P
comp. insurance req‘iired.] Ut.) r V) A j •
*Any applicant that checks box #1 must also fill out the section below showing tbeirworiorrs' compensation policy infernal
t Homeowners who submit this affidaVit indicatirug they are doing all work and then hire outside contractors must submit a new affidavit indicating such_
:Contractors that check this box must attached an additional sheet showing the naane of the sub-contractors and slats whether or not those entities have
employees. If the sub-contractors have employees, they must provide their workers comp policy number.
J am an employer that is providing workers' compensation insurance for my employees. Below is the policy andjob site
information. •
.
- • -
Insurance Company Name: .
•
Policy # or Self-ins. Lic. #: Expiration Date:
. . ,
Job Site Address: City/StaWZip:"
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure cOverage . as required Mid& Sectiorl'25A Of MGL c. 152 can lead to the iinPositiori of Criminal; Penalties of a
fine up to $1,500.00 and/or one-year imprisonme4 as well as civil penalties in the form of a STOP WORK ORDER and a hie
of up to $250 00 a day against the violator. Be advised that a copy of tis statement may be forwarded to the Of6ce of
m•-s - of the DIA for insurance coverage iiiiifiCiii: .
_ I do kereby_certifil und • , e p • , • , p , . • fpe c at the information providetabov , - find_Correct____
I
Siq• -tare: .
Phone 4: t aft:
4 , . .)-5,----z - - - •
Official use only. Do not write La this area, to be coinpYaed by city or town
City or Town:
Issuing Authority (circle one): ' - Permit/License # —
_ ............ _
1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector
6. Other ,
Contact Person:
Phone fi:
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction erv'sor: /4 � f f _ Not Applicable ❑ �f(
Name of License Holder : l; f 1 0 . / �J�1'^�-� l a '/. ( I T
License Number
5 ()..C 1 (,�,,,.. ,. I clCiAall ct (gitP
Address Expiration Date
Signature Telephone
9,-yRecdstere LHomne rrttairoveisitent 6i ffract6 , .AEIB a r A' ';',8iliallid Not Applicable ❑
A 0c -1..-A c f frl n '
Companv Name Registration umber
ice, coc LA,- Vi . VLoziA c . e z
Address te Expiration at
1 rA j 0 G7 Telephone r— a l 3J ?
—
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 YI No ❑
I �- F _som Owne x � . i
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 El Replaceme 0 endows Alteration(s) ❑ Roofing ❑
Or Doors NI
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding [D] Other [0]
Brief Work Description of Propo , l a )
tA1 f C 2 A t W .4^��� p V lli\d4 S .
Alteration of existing bedroom Yes l Y No Adding new bedroom Yes K ( N / o
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa C "' ew br nrfitkfi di f ilit t "r "`° 6iii fp,. ttlbteWtTfgtv t fr :
a. Use of building : One Family J Two Family Other
b. Number of rooms in each family unit: - 7 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 wetlan• s? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor belo finished grade
k. Will building conform to the Building a d Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION Ta - OWNER AUTHORIZATIO - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR A' PLIES FOR BUILDING PERMIT
I A V\CL,,,, fri. , as Owner of the subject
property //� r
he . . thorize Pe 4 fl C y !" 1 C'�I, 1- eC�l
to - • my behalf, in - matters relative t• work authorized by this building permit application.
Signat re of Owner Date
I, DIC) I QCfr A , as Owner /A uthorized
Agent hereby declare that the statements : nd information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed u • : -r the pains 0 penalties of p rjury.
e..' 1 i A 'L ■ .
Print Name
ArdWAAMIlliff
Signature of Owner /Agent Pr 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 € - . ... ...w .. ,
Frontage 1 1 ' E I
Setbacks Front = L
Side Li 1 R:! 1 L:; i R:` 1 1.
Rear = El]
Building Height
Bldg. Square Footage 1 1 -i % 171 1
Open Space Footage
p- r ,
( area minus bldg & paved = L____ 1 1.._21 !
parking)
# of Parking Spaces 3 '°°° _-
Fill:
(volume & Location) I 1
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW Q YES 0
IF YES, date issued:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
i
IF YES: enter Book I
I Page I 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 CD Obtained ,Date Issued:
C. Do any signs exist on the property? YES 0 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 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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
City of Northampton 4' ; kit
Building Department _ - 1 �. i ' � 0-
2 \\ 212 Main Street
0 Room 100 , .. 1 . °
Northampton, MA 01060
,,, :
` u
' ., 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 Pro ert Address:
This section to be completed by office
"7 I AQ C Map Lot Unit
R tV 0 c i(,^ A zone ' Overlay District
II Elm St District CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner
Mv- AA,7,
of Record: C lle7
Name (Print) 4 y , Current Telephone Mailing Address: Art
�7 _ 3AL"` - 8
Signature O
2.2 Autho . A • ent: / C - - Z ( - 2 t
Qr Name (Print) 4i Current Mailing Address:
/ / ___ W — 33s—__,
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
ij completed by permit applicant
1. Building C C j 8 (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 1[4
+ + + + J Check Number (� 9 ,
6. Total = (1 2 3 4 5) ��� 6 � /
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
BP- 2011 -0619
GIS #: COMMONWEALTH OF MASSACHUSETTS
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 -0619
Project # JS- 2011- 001008
Est. Cost: $4800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL MCCUTCHEON 062544
Lot Size(sq. ft.): 15507.36 Owner: MACKEY ANDREW & BARBARA J FISC
Zoning: URB(100)/ Applicant: PAUL MCCUTCHEON
AT: 76 PINE ST
Applicant Address: Phone: Insurance:
1526 WESTHAMPTON RD (413) 584 -3352 0
FLORENCEMA01062 ISSUED ON:1 /10/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 16 REPLACEMENT WINDOWS
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 1/10/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner