23B-070 (3) 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
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
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 oftlfassachusetts
--7--4,---.2.— Department of Industrial Accidents
Office of Investigations •
:...-, =t-Jitlx--- '.P
% 600 Washington Street
=::14— #
: = Z Boston, MA 02111
. . , www.mass.gov/dia •
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Ple , e Print Legibly
Name pusiness/Org-aniza tion/Indivirt , nn1): fl )
P
Address: `'; MIKA V-R - '11.1A, hi -..t a.% - c..A.. A
City/State/Zip: - _ P one.#:
h *- 7 - 3"1 — 3 S -
. "
Are you an employer? Check the appropriate box: 1 Type of project (required): /
• 1. 0 I am a employer with 4. D I am a general contractor and I
6. 0 New construction
have hired the sub-contractors
employees (full and/or part-time).*
lisird on the attached sheet 7. 0 R.emodeling • 2.. In am a sole proprietor or partner-
These sub-contractors have
• ship and have no, e,..loyees 8. 0 Demolition
einTloyees mad have workers'
worldng for me in any capacity. 9. 0 Builel+Wg additiOn
_ comp.in.sitrance.t.. .
[Ne vrerkers' comp. insurance
required.) 5. 0 We are a corporation and its 10.0 Electdcal repairs or additions
3. 0 I am a homeowner doing all work officers have4xercised their .
11.0 Plumbing repairs or ariditions
myself [No workers' comp. right Of exemption per MGL
12.0 Roof repairs . •
insurance required.) t • c. 152, § 1(4), and we have no ,
13.0
employees. [No workers' Or
comp ins required)
*Any applicant -that checks box #.1 must also fin out the section below showing their - workers' compensation policy information.
t Homeowners who submit this affidavit int:Heating they are doing all work and then /dm outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an arlditional sheet showing the name of the sub-contractors and state whether or not those entities have
employees lithe sub-contractors have employee; they must provide their workers' comp. policy number.
l 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/State/Zip:*
Attach a copy of the workers' compensation policy declaration page (showing the policy number and exgration date).
Failure to secure cOverage . as required ilia& Seed OfFrIGL c 152 can lead to the imposition of aiming penalties of a
fine up to S1,500.00 and/or one-year imprisonment as well as civil penalties m the form of a STOP WORK MDE12. auda &_.e
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Effeittions Of the Da for insurance Coverale - VerificatiOri.
Ido hereby certifr u ' / / p , 7 and pen ,,,* ' s o petjtay that the infonnationprovidedibov , i. , , , orrert
- -- -- - -- -
, ..__ /
0 till - Luxe: d, i
, ,
.... - ' ? •
Phone : — S F
• -
# , 3
5 (-I
Officio' I use only Do not write in this area, W be completed by city Or towttOffwiaL
City or Town:
Permit/License #
Issuing Authority (circle one):
"-
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electricalinspector 5. Plumbing Inspector
6. Other
Contact Person: '
Phone #:
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction S , rvis • r: Not Applicable ❑
Name of License Holder : V . ji :A_! le,
License Number
Address Expiration Date
Signat a Telephone
9 Reaisiere l oini lrrigrolydtit8 " Co ntract r `.,a. ',. " ate £ . Tt Not Applicable ❑
M C-CA C
Company Name Registration Number
f 2 2 G w 4 ttAiP10 PCA" c(12 /I
Address Expiration Date
� (4
�c�.eti �p � - Telephone
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 ❑
1-,L.T,i'matkmeF
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
N
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [I] Siding [CU Other [O]
Brief Description of Proposed Op �) ()_, . Li "� f _ � � I3r I (_
Work: J'J✓ ` cQ.�/� �/� et`r l
Alteration of existing bedroom Yes Y \ No Adding new bedroom Yes K N
Attached Narrative -r'. Renovating unfinished basement Yes pc, No
Plans Attached Roll Ghee
sa.:lid. erne tense -an ridditta :fr ixtstirii ffoi rti ,..ceiii`�r(' . the:..faifaivinnq:
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 stones?
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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNE S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
4 ._ ,,, / (o - �/l ,� - as Owner of the subject
property
.
hereby authorize V \ 0,. � c� lf
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I I GO \ l -_ ` `""`'t^ , 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 t
lie_.
ains and penalties of perjury. CE,k..)
\) \ , a Print Name 7
3 I(
Signature of Owner /Age t ' Date
w
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Inf ormation
Existing Proposed Required by Zo ng
This column to be ed in by i t j
Building Departm t 44 j iii
I t. 141.1111 ..,....,.
Lot Size I
Frontage w 1 `
Setbacks Front i i 1 I
Side L:= J R: a ..... L:' _1 R:' ? F
Rear = = 4 1
Building Height r i
Bldg. Square Footage I 1 -i % t 1
1
. Open Space Footage % p
(Lot area minus bldg & paved 1 _ ? }
parking)
I i
# of Parking Spaces ;
Fill: 1 5 .,
(volume & Location) --
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO b DONT KNOW 0 YES 0
IF YES, date issued:i i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
a �
IF YES: enter Book Pagel ? and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO t21 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 Q ,Date Issued: ,
C. Do any signs exist on the property? YES 0 NO ►!r
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 gi
IF YES, describe size, type and location: I
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 ®4
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
*. r
e t truss S w 4 3 '
City of Northampton '" R , ° -- k
f Building Department ! u # x�
ti-- 212 212 Main Street ' s r , i , < . ..... . -4 - , �¢ ,
k `� Room 100 7 rE®-
%tag Northampton, MA 01060
- } 13- 587 -1240 Fax 413 - 587 -127
'ATION 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
C c' map Lot Unit
-- t Zone ' OveflayDistrict
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
S6 1 e � c, 7? ,4.Tly /o ff ( c
Na rint) s ' - . Current Mailing Address: c ,
Ce 1.i ) ( G _ r Telephone -
Signature /
2.2 Au u9 rize • • ent• `
Name (Print) / / Current Mailing Address: _
Signatur • / Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building -- ^— (a) Building Permit Fee
2. Electrical # ---� (b) Estimated Total Cost of
' / Z ' Construction from (6)
3. Plumbing 4 s•-.�, --- Building Permit Fee
4. Mechanical (HVAC) V
5. Fire Protection d
6. Total = (1 + 2 + 3 + 4 + 5) 7 -'7 l' Z S Check Number 3l '--
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0721
APPLICANT /CONTACT PERSON PAUL MCCUTCHEON
ADDRESS /PHONE 1526 WESTHAMPTON RD FLORENCE (413) 584 -3352 Q
PROPERTY LOCATION 108 SOUTH MAIN ST
MAP 23B PARCEL 070 001 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 �!
Typeof Construction: UPDATE KITCHEN & BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 062544
3 sets of Plans / Plot Plan
THE FOL G ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN O ATION PRESENTED:
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
P . . :el.
Air G < ` `/
Signa - 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.
108 SOUTH MAIN ST BP- 2011 -0721
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23B - 070 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 -0721
Proiect # JS- 2011- 001191
Est. Cost: $27925.00
Fee: $167.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL MCCUTCHEON 062544
Lot Size(sq. ft.): 23696.64 Owner: RYAN SHEILA K & JOHN E DAHL
Zoning: URB(100)/ Applicant: PAUL MCCUTCHEON
AT: 108 SOUTH MAIN ST
Applicant Address: Phone: Insurance:
1526 WESTHAMPTON RD (413) 584 - 3352 0
FLORENCEMA01062 ISSUED ON:3/15/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: UPDATE KITCHEN & BATH
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 3/15/2011 0:00:00 $167.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
108 SOUTH MAIN ST BP-2011-0721
GIS -a: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23B - 070 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 -0721
Project # JS- 2011- 001191
Est. Cost: $27925.00
Fee: $167.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL MCCUTCHEON 062544
Lot Size(so. ft.): 23696.64 Owner: RYAN SHEILA K & JOHN E DAHL
Zoning: URB(100)/ Applicant: PAUL MCCUTCHEON
T 1 0 8p SOUTH MAN ST
A?': 108 �i.J t.. i 1 1 ♦:J Y
Applicant Address: Phone: Insurance:
1526 WESTHAMPTON RD (413) 584 -3352 0
FLORENCEMA01062 ISSUED ON:3/15/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: UPDATE KITCHEN & BATH
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
41 .r Footings:
Rough: r - x41 , ' ough: L (43 .f/ House # Foundation:
Driveway Final:
Final "
' ` al: ,
743— // Rough Frame: k — qv'
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:O,K 47_ I/c4/ "..
,
j
Final Y i ll Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND RE i�.`
di .
eit.4
Certificate of Occupanc ' . nature:
FeeType: Date Pai : Amount:
Building 3/15/2011 0:00:00 $167.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner