41-017 (5) 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
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
Date
Address of work
location
s
• " • 7
The Commonwealth of Massachusetts
Department of Industrial Accidents
g _fr ►� ' Office of Investigations •
— �j= ..... 600 Washington Street
ip —A
_.._ _ Boston, MA 02111
:. • ' www.mass.gov/dia •
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
A licant Information Please Print Legibly
Name ( Business /Organization/Indiviclnal) : '' di"? 11 /--. ,
Address: / -?/ lire -G GA L -
City /State/Zip: rf - - Phone. #: 3 7 4
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
employees (full and/or part-time).* have hired the sub- contractors 6. ❑ New construction
2. ❑ I ant a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no e-loyees These sub - contractors have. 8. ❑ Demolition
working for me in any capacity. er Ioyees have workers' • 9 Bun ' : addition
[ N o workers'- comp. insurance _ comp. nsman # - - -
required.] - 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have xercised their . 11. - Plumbing n - r
❑ repairs or additions
• right of exemption per MGL
myself [No workers comp. 12.0 Roof repairs -
insurance required.] t • c. 152, §1(4), and we have no
employees: [No workers' 13. ❑ Other
comp. insurance required.].
*Any applicant -that checks box #I nsrstalso fill out the section below showing their worice s' corapeasabon policy information:
t Homeowners who submit this affdavit:indenting 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 name of the sub-contractors and state whether or not 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 Mader Section Of /CIGL c. 152 can lead to the imposition of cri 1 penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties is the form of a STOP WORK ORDER and a time
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investi2ntions of the DIA for insurance coverage veriftcat on _ ...
_ Ido hereby _certify under the pains and penalties ofperjury that the information provided .above_irtrue_andcorred.
l
Signature: '' / / pate: -- 7f r ,/Z 7/ . .
Phone#:
Official use only. Do not write in this area, to be completed by city or town offciaL
City or Town: Perniit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical,Inspector 5. PIumbing Inspector
6.Other t^ •
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: .�/ Not A plicablee 0
Name of License Holder :l b n J / l �/� / L G V
License Numb r
` if id
Add ss Expiration ate
6
Signature Telephone
9.. Rettistf" rid - kilTielmprov rnent:G nttidaft . , , l „ . o, .... ,. 7 , , Not Applicable ❑
Company Name Registration Number
P/741 4- \
Address Expiration Date
Telephone 6 7/
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 ❑
gr.1
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 ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D ,
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C7 Siding OE] Other [0]
Brief Description of Proposed p
Work: /7 Pp /Pp/4 C P rh Q., / O r p S'/ Olin
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa, t .Ni iiiii a ' i eidtftcft87 i#- five siiil iiptete the fbIIow il'c :
a. Use of building : One Family Two Family Other
b. Number of roams in each family unit: Number of Bathrooms
c. Is there a gars. - attached?
d. Proposed Square fo • age of new construction. r' ensions
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 , -tlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or - ar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City wate upply
SECTION 7a`- OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I , as Oar /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 pains and en 'ties of perjury.
(// ei
Print'(1ame
,4lh ek/ I ch c ityu5 42 Ti, O ot- eP'ia
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 L v _ __ _....,_ __ _ _
Frontage I L. $
Setbacks Front ' I 1 ' I
Side L t ' ` R:1---....1 .. L: R:' . r
3
Rear 11 1
Building Height r F -- I
Bldg. Square Footage \ s, 1 % E= i i
Open Space Footage % €
(Lot area minus bldg & paved ---1 I _ ! � , i i .
parking)
\
_
S , _ A .....
# of Parking Spaces l \ _ M .
Fill:
(volume & Location) l ;
A. Has a Special Permit /Variance /Finding ever 1\e- n issued for /on the site?
NO 0 DONT KNOW 0 , YES 0
IF YES, date issued: \ I
IF YES: Was the permit recorded at the Regi • ry of Dee ds?
NO 0 DONT KNOW iii 'YES 0
IF YES: enter Book d Pag �` - and /or Document #
B. Does the site contain a brook, body of ater or wetlands? • 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need be obtained from the C Commission?
Needs to be obtained 0 Obtained ,Date Issued
C. Do any signs exist on the prope ? YES 0 NO 1
IF YES, describe size, type a d location:
D. Are there any proposed changes to or additions of signs intended for th- 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 - re 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.
� r -
City of Northampton
Building Department
212 Main Street `
Room 100 .E =
Northampton, MA 01060
��
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
/l 7 We 27/1 aN1 ,pi0k Rd. Map Lot Unit
`Zone - '_ Overlay District
Elm St District ? CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: 0/
A )4 e F f A c h a / 4,c , 7 P // 941 West ``i a Alp 7 t Na vt * he
Name (Pri t Current Mailing Address: /
Name N 5,6 6
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 by permit applicant
1. Building $ / C) 0 6C� 1 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee 3 (71(
4. Mechanical (HVAC) 51 D 1 t4
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
1144 WESTHAMPTON Rid BP- 2010 -0852
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Mlock 41 - 017 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit # BP- 2010 -0852
Project # JS- 2010- 001262
Est. Cost: $10000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RONALD MISTARKA 069836
Lot Size(sq. ft.): Owner: CHAMPAGNE ALBERT A JR
Zoning: RR/WP /WSPII Applicant: RONALD MISTARKA
AT: 1194 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
122 WEST ST (413) 575 - 1271
WEST HATFIELDMA01088 -0519 ISSUED ON:4/1/2 01 0 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT SIDING
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:
FeeTvpe: Date Paid: Amount:
Building 4/1/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo