23D-172 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
• 11 - • • • - • • • .xacess 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
----- _- - - - - pe -ts-in -conj unction_. to_ thebuilding ._permitissued,_ 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
1, 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.
--ate
Address of work
location
=
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
te= 600 Washington Street
Boston, MA 02111
;� www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): SC-e)
1 i
Address: 6 U L L.PC
City /State /Zip: / L.-/D i) 01 V Phone. #: 5-3? V
Are you an employer? Check the appropriate box: Type of project (required):
1. Q I am a employer to er with 4. Q I am a general contractor and I
6_ 0 New construction
employees (full and/or part - time).* have hired the sub- contractors
listed on the attached sheet. 7. Q
2_ am a sole proprietor or partner- Remodeling
ship an�l have n a loyees These sub - contractors have. 8_ Q Deno; on
for me in any ac' employees and have workers'
worltin
g y cap ity 9. Q Budding addition
[No workers' co. insurance comp._nlsrrancP_
p
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. Q I -am -a homeewaer -do g-a work -- office _hav ercised their ___11 J glumbmg -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 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 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.
Iam 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 criminal 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 , re
of up to $250,00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Offi-A of
Investigations of the DIA for insurance coveraze verification.
_ I do_hereby certify under the pains and s enah%ps of perjury that the information provided _ahave_is_true_aud_correct __ _._ -
Si
1[�7 �.
Silas tore: , �/ � /A � � ate.
Phone #: > J J
Official use only. Do not write In this area, to be completed iy city or town off ciaL
City or Town: Permit/License #__
Issuing Authority (circle one):
-`I: Board of Health 2. Buil -ding Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector
6.Other !
Contact Person: Phone #:
f
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: --�, Not Applicable 0
Name of License Holder : R 1 L ( " t f& D ,3 � �- v I ? 0( /
License Number
Address Expiration Date
�C–)
Signature 1744 1744 \ Telephone t l
3 7
9.. Registered Home improvetttent Contractor j w Not Applicable ❑
R \ c M Y k.(1v � i b
Company Name Registration Number
Z� v
LC- A- A V im, `?j - - D
Address Expiration Date
`1 \<- Telephone S 3 J -(a la
I-
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G 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 ❑
.1I t44"000
_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, ui is intended to lie, 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
o ampton e r i tna ces, . a e :r . i • ` . _ r. * - ® tts-Genera1 aw-s- 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 El New Signs [0] Decks [E ] Siding [0] Other [ltij'
Brief Description of Proposed 1'
Work: / ii)0 /) S O Ve,
Alteration of existing bedroom Yes _ No Adding new bedroom Yes No
Attached Narrative . Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa_ i'f.Ne*tiouse and ar eck�'it o�.to "existinq'ho is�ncl,`complete the .foliowlrtq:
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 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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
1 Aff4/.441g' ar" A,k , as Owner /Authorized
Agent declare that the - tements a.: information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Si. ned u -er the pains and pen - • • -jury.
Pn N. a IMF, 4r111W
Signatur of Offer /Agent Date
J
A
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 _ ._._.__ _ __, ____. __..._
Frontage '
Setbacks Front
Side L :°' .____. R :M.___._.._. L:_______: R:'....____.
Rear £ _.� _ .
Building Height :— - °- -..,
Bldg. Square Footage --
Open Space Footage %
(Lot area minus bldg & paved
parking) I
# of Parking Spaces
Fill:
(volume & Location) i i __. w._ ................—
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:; i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book i Pagel and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
DD.` re— tFier`e any proposed changes to or additions o signs nten edfor e 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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
Building Department C�ar�Onevuayer�
212 Main Street se - ® mu .
"ma
Room 100
Nocthampton, MA 01060
phone 41311587 -1340 Fax 413- 587 -127 a E
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Prope Address:
This section to be completed by office
,2 L P:9 Map Lot Unit
eta 64' 01010-z_ Zone Overlay District
EIm St. CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: c -
_ A -;fy, 2:400:4 //( 3 10
/ Name lj urre t ailing A r '
gr �..�a«��/ TelEp'ho e
gnature
. 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
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) d i)
5. Fire Protection J )
6. Total = (1 + 2 + 3 + 4 + 5) I Check Number !a' 7 / Ll 45"
This Section For Official se Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
48 BAKER HELL, RD BP- 2010 -0504
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D - 172 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- 2010 -0504
Project # JS- 2010 - 000697
Est. Cost: $2750.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD SCOTT 83108
Lot Size(sq. ft.): 23478.84 Owner: RYAN G ANTHONY & AUDREY J
7nnin : tIRB(1NNZ Applicant: RICHARD SCOTT
AT: i3 BAKER H'LL RD
Applicant Address: Phone: Insurance:
20 BULLARD AVE (413) 533 -6340
HOLYOKEMAO1040 ISSUED ON :11/6/2009 0 :00 :00
T() PERFORM THE FOLLOWING WORK INSTALL WOODSTOVE
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: O /C
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIO
Certificate of Occupanc Signature:
FeeType: Date
Paid: Amount:
a
Building 11/6/2009 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
0
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\s' se\ ' 80' .
„, 23D-145
# Craig A. Porter
F/ Jason M. Todd Book 3217 Page 62
i Book 5462 Page 229
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