23B-075 a
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 staQes, 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
permits 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
I di.
f 1,
• s.
The Comm on weait�? of 4Iassachuserts
_ r
Department of Industrial Accidents
O ce of II v esti` a :
_ — 600 rT ashin Street
- — Boston, A 02111
• www.mass.gov/aria
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plurnbers
ADasicant Information PIease Print Legibly
Fame ( Business /Organizarion/Individual): � , _
Address: • / I � ;.% �/ G
/r ��
• r
Civ State /Zip: A- Phone r=: J 'CY,
Are you an employer? Check the appropriate box: Tvpe of project (required):
1. ❑ I : - employer with 4. ❑ I am a general contractor and I
6. ❑ New construction . ployees (full and/or part - time).* have hired the sub - contractors
2. I am a sole proprietor or partner- listed on the attached sheet. i. ❑ Remodeling
ship and have no employees These sub - contractors have 8. D Demolition
employees and have workers'
work ng for me in any capacity. 9 ❑Building addition
[No workers' comp. insurance comp. insurance.
required_.] d. W e are a corporation and its 10. Electrical repairs or additions
3. C=1 I am a homeowner doing all work
officers have exercised their 11.0 Plumbing repairs or additions
mysel f. o workers' comp. right of exemption per MGL .,
1: ❑ Roof repairs
insurance required.] c. 152, §1(4), and we have no I3.❑ Other
employees. [No workers'
comp. insurance required.]
`Any applicant that checks box "l must also fiii out the section below showing their workers' compensa policy information.
Homeowners who submit this affidavit indicative they are doing ail work and then hire outside contractors must submit a new affidavit indicating such.
"C ontractors that check this box must attached an additional sheet showing the name of the sub - contactor and state whether or not those entities have
ern love 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 Co Name: ______O ' -, ,I
Policy # or Self -ins. Lic. #: Expiration Date:
fob 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 under Section 25A of MGL c. 152 can lead to the imposition of criminal 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forNarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penaltie serjury that the information provided above is true and correct.
Si 2 1�/ 2� ` ff
Date:
Phone #: W _
� j
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town: Permit /License # t
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City /'Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
I i I
i Contact Person: Phone =:
N.
'A t
Sc•DTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Si ervisor: I NOt Applicable ❑
Name of License Holder : ' ° ��f
9 License er
AKe rte/
address Expiration Date
signature Telephone }-(/
/
45■10■11k4Iit—ror
r_ Re• stared Home Improvement Con* ,j.„ ar Not Applicable ❑
� ✓ / /�►� // 7 /5
:omoanv Na � Registration Number
.ddress Expiration Date
Telephone j5? ` /3) e
ECTION 10- WORKERS' COMPEN:SAT1ON INSURANCE' AFFIDAVIT (M.G.L. c. 152, §..25C(61)
orkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit. •
Oned Affidavit Attached Yes....... ❑ No ❑
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 730- Sixth Edition Section 1033.5.1.
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, von may be Iiable 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
a IN
/ .
r w
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
i I
New House fl Addition I 1 Replacement Windows 1 Aiteration(s) = Roofing � //f
Or Doors 0 i
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [t_J Siding [p; Other [Qj I
Brief Description of Proposed
Work: /d. ,40 A ■ . Az.e :
Alteration of existing bedroom Yes No Adding new bed P Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roil - Sheet
ea. ff NeW hOUSe aria ar eddiiiOn t ex €nQ i� c om p let e 'thef o l( olti ina:
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. cf wetlands? Yes No. Is construction within 100 yr_ flocdpiain Yes No
Depth of basement or cellar floor below finished grade
k. Will building conform tc the Building and Zoning regulations? Yes Nc .
I. Septic Tank - City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION TO S E COMPE�ETED
OWNERS -AGENT OR CONTRACTOR APPLIES: FOR BM MUTING
.
I, `` �/ _ / ..1:4 as Owner of the subject
property or
hereby authorize . /L /!t. ^ / -e'
to act on my behalf, in a "ttiers relative to work a on..zeedd by this buuilidii -nag permit application.
A. ....., '_.■ _I:6 ' Ile i '- , " - r
Sign- ure of Owner Da
i /■rdAile ',ae /��`` - , as Owner /Authcnzed
Agent hereby cure that the stateme's . information on the foregoing application are true and accurate, to he best of my knowledge
and belief.
Signed under the pains and penalties of pe.rju . ►--
Print Name , , :ate ;
e∎ cnature or
IF ,'Agent
to- tit
0
,o, It
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
LotSize r _. __ w _,.. .-. -,_ _. „.._. ,.., _... ...__,.
Frontage
Setbacks Front ,. . _......_. _ . ___ .._.__..
I
Side L:..,..._..._. R. _ . .
Rear
Building Height
Bldg. Square Footage _.... % _._.__.
Open Space Footage I
(Lot area Footage
bldg & paved -- --
parkin t)
# of Parking Spaces -° __ _
Fill:
(volume & Location) .-_— ---- --
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES _ _._
IF YES: enter Book Page 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 0 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 con n rrUrI plan
that wit disturb over 1 acre? YES 0 NO 0
IF YES, then - a Northampton Storm Water Managemenf Permit from the DPW is required.
Department use only
1 City of Northampton Status of Permit:
Building Department ff rEvay rris t
' 212 Main Street
S /Se Av
Room 100 FttlaterlihlelFAvaitability
Northampton, MA 01060 Two Seta of Structural Pl a n s
�? .iii orte ^ 1y> 87 -1240 Fax 413 -581 -1272 Plot/Site Plans
Other Spec
1 A.PPL1CT1N TO CONSTRUCT, ALTER, REPAIR, R OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SlTE_INFORMATION 1
1.1 Property Address: This section to be completed by office
? dr--P J �' Map Lot Unit
�-''P Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 1
2.1 Owner of Record:�y 4
Name (Print) urrent Ma Address:
t -ei, / �i Z/ ����(Y c 7 2-(1 y" elephone
Sign t� ure
2.2 Authorized • .. -nt: ,,/ /fr.
/ , ' `. ../// 3 _./t / �./ /
Name (Pent) : ' Current Mailing Address:
i
i _ .1 .41/ . ` G - 7 `— C3 , g( Signature Telephone '
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item I Estimated Cost (Dollars) to be Official Use Only
cou by permit aoplicant
1. Building r I Fee
2. Electrical / (b) Estimated Total Cost of
Construction from (6)
3- Plumbing Building Permit Fee
•
4. Mechanical (HVAC) 3
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) I Check Number ( I fO 3 6
This Section For Official Use Only
✓�P � ijj � 6 I` Date
Building Permit Number. Issued:
Signature:
Building, Commissioner /Inspector or buildings Date
nk�
`f�3
mew
gage BP- 2011 -0110
GIS #: COMMONWEALTH OF MASSACHUSETTS
Fdr,f 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 -0110
Project # JS- 2011- 000194
Est. Cost: $8000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERTS ROOFING
Lot Size(sq. ft.): 13590.72 Owner: MCDONALD ROBERT J & HELEN H
Zoning: URB(100)/ Applicant: ROBERTS ROOFING
AT: 82 SOUTH MAIN ST
Applicant Address: Phone: Insurance:
30 EDWARDS RD
WESTHAMPTONMA01027 ISSUED ON:
TO PERFORM THE FOLLOWING WORK: Strip & Reroof
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 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner