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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
• N. - • - ., • .. • - - . - tha . e buildin . de • artment 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 -i-n- conjunction..to_ the_ building ._permitissued,_ 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
r
i� -7
-f �0LIt�' PUL understand the above.
(Home o4vner /resident's sig t re requesting exemption)
I will call to schedule all require building inspections necessary for the building permit
issued to me.
Address of work
location 32 — YfriiP
7
ro
• . The Commonwealth of Massachusetts
Department of Industrial Accidents
it _ 7; t l Office of Investigations •
t
_.. fi
tt tt 600 Washington Street
Boston, MA 02111
r s ' t www:mass.gov/dia
-Workers' Compensation Insurance Affidavit Builders/ Contractors /Electricians/PIumbers
Applicant Information _ Please Print Le Oily
Name ( Business /Organization/Individual): I ' 4 if, 5 .'y 1 _ i ��r- '
Address: 100 (& u nn✓ ille9 -
City /State/Zip: EA 14 )4 m4 o i O b l Phone #: CO 3) J J— o
Are you an employer? Check the appropriate box: Type of project (required): i
1. D I am a employer with 4. 0 1 am a general contractor and I
Y 6. ❑ New construction
employees (full and/or part-time).* have hired the sub- contractors
2. I am a sole proprietor or partner- listed on the attached sheet. 7. l./ Remodeling
These sub - contractors have.
ship and have no: employees 8. Et-Demolition
working for me in any capacity. employees and have workers'
Y P ty 9 Q Building addition
[No workers' comp. insurance ._ comp. .insurance.; .
required.] 5. 0 We are a corporation and its 10 Electrical repairs or additions
] officers]iavexercised rho_ 11 in repairs or additions
3. CI J-am hemeowner-doing- all -work — — .� lu b g -epairs
myself [No workers' comp. . . right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required]
*Any applicant that checks box #1 must also 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 such.
Contractors that check this box must attached an additional sheet showing the name of the subcontractors 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 under Section 25A of MGL c. 152 can lead to the imposition of criminii penalties of a
fine up to $1, 500.00 and/or one :year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a flue
of up to $250.00 a day against the violator: lie advised that a copy of this statement may be forwarded to the Office of
Investisations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above _t rue_ and correct _ _
�`' wry % - - - / m _
i - . , lure: i i� /" Date: . 'f' /---- _
Phone #: 0 ,C C�jf— d
Official use oiily. Do riot write iii tli s amen, — to be compreted by city or town of ciaL
City or Town: Permit/License #
Issuing Authity (r on)
i.- Boa-rd of Health ci 2. cle Buildi et Department 3. City/Town CIerk 4. EIectrical Inspector 5. Plumbing Inspector __ ___
6.Other "
Contact Person: or Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ •
Name of License Holder :
License Number
•
Address Expiration Date
Signature Telephone
9' 1 2 O e t ' e d � ' I t - a ar et6i - Not Applicable ❑
LL 1)i J WJ4 7v 417 ,ii
Company Name Regist tion Number
X019 ( 4WD/Jilt- W/.9 y e /�1
Address Expi atio Da te
01 C 4 Telepho ' ��a G
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 ❑
le
;� Est ;• ,ar � e,,-�n _ �
a : o m O a 03 .411 €I; .F I
Lhe_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 1083.5.1.
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" ce • r • s and assumes responsibility for compliance with the State Building Code, City of
�o ampton •retnan -s, a • • r . .• r . r • . -- - . - -ral=Laws- Annotated.
Homeowner Signature 6e � 1 , '.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all aoolicahle) I
i
New House ❑ Addition ❑ Replacemen Windows Alteration(s) ! . Roofing ED Or Doors
Accessory Bldg. ❑ Demolition tn.l. New Sighs [0] Decks [I] Siding [DJ Other [D]
Brief Description of Propo ed
Work: 'x/7 , - N % e & m e 1 1 , J J L :- 1 2 4 0'm / O 2 a - L y / 4 7 r a o r . 01 -AL) A"i zr N�
Alteration of existing bedroom Yes :/ No Adding new bedroom = Yes " No 4"x/9
Attached Narrative Renovating unfinished basement Yes i ./ No
Plans Attached Roll - Sheet
Ee?
a. Use of building : One Family Two Family Other _
■ b. Number of rooms
' • n 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 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN ,
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, �� pi'4},./1 /�""- )q[' as Owner of the subject
property j�/ r /�
hereby : • 'ze d Y.l ld Y '�'/ °_ �/ C:�'J v►� t` L L-
to act • . ehalf, in all matters rel. ' - to work authorized by this building permit application.
All 1 I A L-■- ;111 •0■_
Signature of r er Date
I, / /4.4 & fiCZ__ , 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 helipf.
Signed nder the pains and penalties of perjury.
c P ' X71/ /C"
t
Print Name
A A I W A . . . . . . . . ) - - A. w
Signature • 0 ner /Agent Date
%,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zonit
This column to be filled in by
Building Department
t
Lot Size
1
Frontage ? ._.._ _ - •
Setbacks Front = 1"---1 L, l
Side L: I R:.. . La,` R: 1
n,.W,.i 1 1
Rear
--
Building Height r-° _ ._._.._ i .__ _
Bldg. Square Footage F 1 % ° "° FT Yµ_
Open Space Footage % 1
t area minus bldg & aved
(� P a nd _
.arkin_
# of Parkin • S laces L
_......__e . _.... .n.�.__,
Fill: I
v & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO I; DONT KNOW 0 YES 0 '
IF YES, date issued:' I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
IF YES: enter Book i I Page! ! and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO cilL DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained (3 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO GI
IF YES, describe size, type and location:
--- D:—re t ele aiy piroposed-c angel to or a t i ons o signs m eh ed=for tTie property ? YES Q 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 ilr
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
FC 4 1,T7-'7477.1Z7 , 1
ftEC„,‘NIE Ci of Northampton
Bui ding Department a ,, fIttto
2 12 Main Street
Room 100 9��
�NS h pton, MA 01060 ��� " t��
DE $ OF BUILD � -1240 Fax 413 -587 -1272
oThAM a -+ -
M v
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
32— ier i > p Lr - • map Lot Unit
tT LQ / i / 4 "'Zone Overlay' District
tZ�
Elm St . District_ CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
- e et m't
Name (Print) • Current Mailing,Adi re7,s: S
{ - Telephone �`// S J
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 (a) Building Permit Fee
it/49
2. Electrical (b) Estimated Total Cost of
3Ci 0 4 Construction from (6)
3. Plumbing
/0- 0 0 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection �s J
6. Total = (1 + 2 + 3 + 4 + 5) Check Number �pk
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
Building Commissioner/lnspector of Buildings Date
,,/ riot
File # BP- 2012 -0860
APPLICANT /CONTACT PERSON PICK STEPHANIE EMM ,►
ADDRESS /PHONE 32 MIDDLE ST FLORENCE (413) 586 -5652 0
PROPERTY LOCATION 32 MIDDLE ST
MAP 23A PARCEL 127 001 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 Q �j
Fee Paid / d0
Typeof Construction: DEMO PORCH & CONVERT KITCHEN TO DINING ROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 165392
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFWVIATION PRESENTED:
Approved 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
Demolition Delay
A
Si re of I' uilding 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.
32 MIDDLE ST BP- 2012 -0860
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A - 127 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- 2012 -0860
Project # JS- 2012- 001514
Est. Cost: $18169.00
Fee: $108.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WILLIAM GEMMELL 165392
Lot Size(sq. ft.): 14853.96 Owner: PICK STEPHANIE EMM
Zoning: URB(100)/ Applicant: PICK STEPHANIE EMM
AT: 32 MIDDLE ST
Applicant Address: Phone: Insurance:
32 MIDDLE ST (413) 586 -5652 ()
FLORENCEMA01062 ISSUED ON:4/5/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: DEMO PORCH & CONVERT KITCHEN TO
DINING ROOM
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 4/5/2012 0:00:00 $108.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner