24A-051 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
regulatinns.._The i._ _n_sp process requires tha th e 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-coujunction._to_ the - building n .rmirissued,_ 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 me.
Address of work
location
7.
The Commonwealth of Massachusetts
Department of Industrial Accidents ✓
v
t _ k►. _ Office of Investigations •
wsi
600 Washington Street
Boston, MA 02111
www.massgov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/In ):
Address: Pcj3 kJ
City /State/Zip:,, 441 d' S j . Phone. #:
Are you an employer? Check the appropriate box: Type of project (required): 1'
1.0 I am a Y lo. er with 4.. 0 I am a general contractor and I
6. ❑ New construction
e es (full and/or part- time).* have hired the sub - contractors
2. I mist a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no ei1oyees These sub - contractors have. .8. ❑ Demolition
for me in any capacity. employees and have workers'
working
Y P ty $ 9 Q Building addition
[No workers' comp. insurance coinsurance....
required.] - 5. 0 We are a corporation and its
10.0 Electrical repairs or additions
3.0 I aiemeowaer dai$ officers Dave °exez i� e c d h__ 11.0 Plumbing repairs or additions
myself, [No workers' c ow k right of exemption per MGL 12. lafpairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. Other
comp. insurance required.}
*Any applicant that checks box #1 mast 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.
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. Lie. #: 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 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 fire
of up to $250.00 a day against the violator. e advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penarth s of perjury that the information provided_above_is_true_and correct~_- ___
_Signature: Date; /Ll
Phone #: fa)
Official use only. Do dot Witte gi tfiis area; to be completed by city or town gf, iciaL
City or Town: Permit/License #
Issuing Authority (circle one):
-- - f_ Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector _ __
6.Other r .
Contact Person: Phone #:
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
—"–
Name of License Holder : 1 j / W «--- AND Si
f License Number
Po ,44 c,/e)-3 11/'12`
Address ��// lion to
S' re Telephone
9. R&giSterd +lome erneriteantridto" $ h Not Applicable ❑
Company me Registration Number
12 AU04b -- ■-• '7 /1 I 5 ' 11
Address E tion ate
PJ 0`/A 3 Telephone fr3 3z1fizo
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 p rmit.
Signed Affidavit Attached Yes No ❑
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 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 referenceto 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
ort amp on r tnances, a e • .. -< • . `. • -- sGeneral Laws-Annotated.
Homeowner Signature
*r• - •
s
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition El Replacement Windows Alteration(s) 0 Roofing
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[=1 Siding [0] Other [0]
Brief Description of Proposed `` r J
Work: 51."-; le- O ile,. 6,"-
Alteration of existing bedroom " No Adding new bedroom _ Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
ofvewtfailsiTaildt cic or tel acwirqf fta " q tvor t'alf vit*
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
I, S (4) i t IOC r tt (le A01‘; 114' _ as Owner of the subject
property , �'
hereby authorize �{HCi ' )-, Lt..) 63.
to act on my behalf, in all m relative to work authorized by this building p rmit application.
Signature of Owner Date
w
I, , as Owner /Authorized
Agent here d J - are 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 N e
44. -.0.- .... ..A 11111°P p r._ ,---__/,
__
- ureof•w • -nt 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 I ?
Frontage r i ':
Setbacks Front f7-1 1 1 f 7
Side L:. R: J L ._...r.__ I R:' : _..... .
Rear iW.._., ...._i
Building Height . / . i
Bldg. Square Footage i" % r 1 i
Open Space Footage %
(Lot area minus bldg & paved ,,, _ , � w I - -
parking)
# of Parking Spaces '. ----- -- ..._.-
Fill:
(volume & Location) L. —. - - j i_ >- -- . _,1
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 Q
IF YES: enter Book I 1 Page I and /or Document # ^
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
-- " - ` A D. Are there`any proposedclianges to or a i ions o signs inten e` for the property ? YES Q NO 0
IF YES, describe size, type and location: t
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.
ti
V
City of Northampton a. : �,
Building Department - n i 4-
c L r — - 2010 212 Main Street -
Room 100 . '
Northampton, MA 01060 . ,
phone 413 -587 -1240 Fax 413 -587 -1272 1 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
',/ e C, Map c i-filq Lot 0 0 1 Unit
Zone ti l ti 13 04 /Overlay Distnct
EtnSt District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
mot,• c.3 _t tCt41_ dam. ,1\- it i I0 v G 'r(' rl ti lit ivtrizj1n F'V}, 04: -..
Name (Print) C ent Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
- � ^ L -- ?Ol [ / LQ-e-e-i b 4/1A
Name Current Mailing Address:
/13 38f 7100
Signatu Telephone
S CTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
_ completed by permit applicant _
1. Building 3 . j d3 (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) 4 5 775-1'--. Check Number
This Section For Official Use Only
$.Q 1( r 0 1 i Date
Budding Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings- Date
149 BARRETT ST BP-2011-0197
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A - 051 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-2011-0197
Project # JS- 2011- 000344
Est. Cost: $3575.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY LUCE 100515
Lot Size(sq. ft.): 10846.44 Owner: DEAGUILAR SARA NOLAN
Zoning: URB(100)/ Applicant: DEAGUILAR SARA NOLAN
AT: 149 BARRETT ST
Applicant Address: Phone: Insurance:
149 BARRETT ST
NORTHAMPTONMA01060 ISSUED ON:9/7/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: Roof
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 9/7/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner