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94 13 (i/
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
understand the above.
(Home ner /resident's si re requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued tome.
Date R w(^ t -
Address of work
location C7; - let.✓Kr, -c it
?-4.6,y--,, -14-- 6,01, (I--
The Commonwealth of Massachusetts
Department of Industrial Accidents
s ,
Office Office of Investigations
, = T 600 Washington Street
m= Boston, MA 02111
www mass gov /dia
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /organization/individual): 'Ci F(" rip ? t
Address: 5Y ? vu Dr •
City /State/Zip: ›r 4 0(a 6 J Phone. #: 4 ' - (S F9
Are you an employer? Check the appropriate box: . Type of project (required) /
1. D 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. 0 New construction
listed on the attached. sheet 7. 0 Remodeling
2. .0 I am a sole proprietor or partner-
ship and have no a loyees These sub - contractors have . 8. 0 Deonolit
working for me in any capacity. emuployees and have workers'
9 Bit addition
[No workers' cou insurance comp, inetTra nce # _ .. _
required:] 5. 0 We are a corporation and its 10 Electrical repairs or additions
3y I am a homeowner doing all work have xercised their work 11.0 Plumbing repairs or additions
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 Mow showing their workers' - compensation policy information:
t Homeowners who submit this affidavit, indicating they are doing all work and then hire outside contactors must submit anew affidavit indicating such.
IContractors that check this box must attached an additional sheet showing the name of the sub cont{acmis and state whether or not those entities have
employees. lithe 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 .Sectton 25A'ofMGL'c. 152 can lead to the imposition "of crimini1 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 fine
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_
Tnvestikations of the DIA for insurance coverage verification _ .
_ I do hereby_ cerfi the pause and alties ofperjury that the information providetrabove_zit ti _andcorrerx - --
Si lure.
Date: .. /.3 Phone 4: b36' — /P771 .
Official use only. Do not write in this area to be completed by city or town 'offciaf
City or Town: •- Permit/License # �„_
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk . 4. Electrical,Inspector 5. Plumbing Inspector
6. Other .
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable rH
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable
Company Name Registration Number
Address Expiration Date
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 ❑
11. - Home Owner Exemption
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 St of sachusetts General Laws Annotated.
0
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [E] Siding [0] Other [m]
Brief Description of Proposed `, f 1 e " `---
Work: Small expansion of the existing outside deck on the back of the house. /' /
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family X Two Family Other
b. Number of rooms in each family unit: 8 Number of Bathrooms 2
c. Is there a garage attached? no
d. Proposed Square footage of new construction. 84 1 X
Dimensions
e. Number of stories? n/a
f. Method of heating? n/a Fireplaces or Woodstoves n/a Number of each
g. Energy Conservation Compliance. n/a Masscheck Energy Compliance form attached?
h. Type of construction deck
i. Is construction within 100 ft. of wetlands? Yes X 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, , 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
, 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 the pains and penalties of perjury.
Print Name
Vii. 3 a
Signature o /� n 'r /Age r D ate
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 1 1, 90
Frontage
Setbacks Front (�
Side L: R: L S- R: �C '
Rear
Jc.t A. f ikc.
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ver been issued for /on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO (,) DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained i 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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Gu t/Driveway Permit
2 Qi\'� 212 Main Street Sewer /Septic Availability
3 Room 100 Water/Well Availability
0 Northampton1240 Fax , MA 01060 Two Sets of Structural Plans
phone 413- 587 - 413- 587 -1272 Plot/S to Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE O TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: ,/1 This section m by office
5 K a � i-t Ns 1�� ►✓(; M Lot to Unit
�'(,,, f .„Le �� to Zone Overlay be co District pleted
Elm St: District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Jeffrey J. Trapani 597 R iver side Dri ve, Florence 01062
Name (Prin Current Mail A ddre ss: 413- 636 -1599
Telephone
v
V Signat e
2.2 Authorized Agent:
413 636 - 1599 413 636 -1599
Name (Print) Current Mailing Address:
413 - 636 -1599
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cos (Dollars) to be Official Use Only
completed byo permit appl
1. Building 4 450 (a) Building Permit Fee
2. Electrical / m
iN (A Constructio Tot n f rom Cost (6) of
4. Mechanical (HVAC)
3. Plumbing ^, B uilding (b El Permit Fee
(" /
5. Fire Protection N/A
6. Total = (1 + 2 + 3 + 4 + 5) m L �D �ft�"d °'
This Section For Official Check Use Nu Only ber
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -1013
APPLICANT /CONTACT PERSON TRAPANI JEFFREY
ADDRESS/PHONE 597 RIVERSIDE DR FLORENCE (413) 636 -1599 0
PROPERTY LOCATION 597 RIVERSIDE DR
MAP 23C PARCEL 011 001 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 Paid ,50 4
Typeof Construction: EXPAND EXISTING DECK 7 X 12
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
S120 J I0
Signature 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.
597 RIVERS PR BP- 2010 -1013
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: BUIl ,DING PERMIT
Permit # BP- 2010 -1013
Project # JS- 2010- 001493
Est. Cost: $450.00
Fee: $305.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 11891.88 Owner: TRAPANI JEFFREY
Zoning: URB(100)/ Applicant: TRAPANI JEFFREY
AT: 597 RIVERSIDE DR
Applicant Address: Phone: Insurance:
597 RIVERSIDE DR (413) 636 -1599 ()
FLORENCEMA01062 ISSUED ON:5/20/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: EXPAND EXISTING DECK 7 X 12
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 5/20/2010 0:00:00 $305.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo