23C-053 1 4
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 buildin2 inspection (before work is
concealed), insulation inspection (if required) and a final buildin2 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
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
p,„,4
k 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 2/3JJn
Address of o k
location - , MJ (L-LO c .) ` )
(e Mfg o f
` T
j . The Commonwealth of Massachusetts
Department of Industrial Accidents
p, =;� 1 1-a i Office of Investigations
. _
: . 4 0: 600 Washington Street
Boston, MA 02111
;;,� www.mass gov /dia .
• - Workers' Compensation Insurance Affidavit Builders/ Contractors /Electricians/PIumbers
Applicant Information Please Print Legibly
Name ( Business /Orgaaization/Indivirina1):
Address: •
City /State/Zip: - Phone. #:
Are you an employer? Check the appropriate box: . Type of project (required): /
1. ❑ I am a loy er with 4.. 0 I am a general contractor and I
y have hired the sub-contactors 6. ❑ New construction
employees (full and/or part-time).*
listed on the attached sheet. 7. ❑ Remodeling
2.. Q I am a sole proprietor or partner-
ship and have no aloyees These sub - contractors have 8. [] Demolition
working for me in any capacity. ei 1oyees and have workers'. • -
inc�rranr # _. 9. • Q Building °addition
[No workers comp. insurance -
10 Electrical repairs or additions
required.] 5. []. We are a corporation and its ❑ � ep
officers ave xercsed their . 11. Plumbing repairs or additions
3 I am a homeowner doing all work ffi h i h ❑ g eP
myself [No workers' co right of exemption per MGL
Ys [N comp. 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 worlcers'- compensation policy information. .
t Homeowners who submit this affidavit,jadicating 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 Fide their workers' comph policy number. . .
I am an employer that is providing workers' compensation insurance for my employees Belo w 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 'eap ration date).
Failure to secure coverage as required under Section 25A ofMGL c 152 can lead to the imposition of Criminal penalties of a
fine up to $1, 500.00 and/or one -year imprisonment as well as civil penalties in the form ofa STOP WORK ORDER and a fe
of up to $250.00 a day against the violator Be advised that a copy of this statement may be forwarded to the Office:. of
Iuveshgations of the DIA for insurance coverage verification , : ..
I do hereby certify , r , ains• :, d penalties ofperjury that the information providedstbove_ ' ` _aniLcorr_ect
Susnatare: d Date: 7
/,0, •
.
Phone it:
3 _ s-3.9 _ ..
.
Official use only. Do not write in this area, to be completed by city or town official
•
City or Town: Permit/License #
Issuing Authority (circle one):
.'1. Board of Health 2. Building Department 3. City/Town Clerk . 4. Electrical ,Inspector 5. Plumbing Inspector
6.Other i- .
Contact Person: Phone #:
,
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Realstered;Hoine tmpro tertientContractar; ZaiLiaiEiiaifiKZZENLW7S 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 eM No ❑
ItAteltwintelOwiteilEtemottait
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 ass . responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Loc - I aws and S • e of Massachusetts General Laws Annotated.
Homeowner Signature �// / —�.
i HOP.-
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 [IJ Siding 01 Other [0]
Brief Description of Proposed ; � D
Work: Y'fiT ,06, �� I / A1 /6
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
siAtNiii fitiiitiiiiiatAiiili oiii iiiii (iii iou'slnq 6416144 the a itoiaiiiici:
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. 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 la - 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 -- I m • ers relative to • rk authorized by this building permit application.
Signa ,r of Ow �/ Date
as Owner /Authorized
Agent hereby . dare that the stateme ° and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed un
t
the pains and penalties of perjury.
Print Name
02 A
Signature of c • `�• gent • 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 1 1
Frontage ' s i 1
Setbacks Front j
Side L: r R:..__.... i L: __. ' R: _I I 1 I
Rear 1 1 i
1 _____
Building Height
Bldg. Square Footage %"— I
Open Space Footage 1
(Lot area minus bldg & paved L. _®„_ 1 ? i
parking)
# of Parking Spaces i
Fill: I ......... ...,. .. ._ ____�,..�_,.— __�,..— ..�._,. „.,
(volume & Location) a
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:I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book € Page and /or Document #'„ __ __ _ T
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
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 Q
IF YES, describe size, type and location: I _ H mN
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
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 Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
City of Northampton , s . _) „ r A
Building Department ° :h 4 "
212 Main Street $ r
Room 100 pv x
Northampton, MA 01060 " < § =. =
phone 413 -587 -1240 Fax 413- 587 -1272 ° g
r . < m ,,3 a<
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
9- 66, Address:
I / 1O) ST Map Lot Unit
m n a/ O 6 L Zone Overlay District
Elm St District' ' CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
gt V m g p,k0„ cd x Sam
Name (Print) Current Maili Addess:
�i35R
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - iESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building rL / 1y5� 00 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) Check Number 17 'tir
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
.WILLOW ST BP- 2011 -0094
GIS #: COMMONWEALTH OF MASSACHUSETTS
lqap:Nopk: 23C - 05i 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 -0094
Project # JS- 2011- 000176
Est. Cost: $2000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 32321.52 Owner: COX KEVIN R & PAMROSE EDEN -COX
Zoning: URA(100) //WP/WSP Applicant: COX KEVIN R & PAMROSE EDEN -COX
AT: 64 WILLOW ST
Applicant Address: Phone: Insurance:
66 WILLOW ST
FLORENCEMA01062 ISSUED ON: 8/10/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: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:
FeeType: Date Paid: Amount:
Building 8/10/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner