24A-062 (2) • •
•
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/footines (before backfill),
sonotube holesjbeforepour), 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= insoected.
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
i3ermits 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
,
ove.
d. la—, understa the above.
(Home er /resident's signature requesting exemption)
I will call t46 schedule all required building inspections necessary for the building permit
issued to
Date 55 l ( l
Address of work
location � cl,,- -F cock, ki t t cJc .
N - 16(� j n r1 n ft e l
• The Commonwealth of Massachusetts
Department of Indu.slrial Accidents. . '
l = (l Office of Investigations •
_, ��= a 600 Washington Street
: - Zt . -. S' Boston, MA 02111
. ;, w ww mass gov %dia
-Workers' Compensation Insurance Affidavit Builders / Contractors /Elect
Applicant Information Please Print Legibly
Name (B usiness /Organiiation/lndividua1): ,
Address:
•
City /StatelZip: Phone. #: •
Are you an employer? Check the appropriate box: . .Type of project (required): /j
4.. am a general contractor and 1 1. [❑ I am a employer with. ❑ 1 g 6.. New constructi
have on - --
employees full and/or arEtiine :* - hired the- sub - contractors — - — -L- — —
( p . _
2.. ❑ I ani a sole proprietor or partner listed on the attached sheet. 7. Q Remodeling .
• These sub-contractors-have- .
ship and have no employees h-- - - . 8. ❑Demolition
working for me in any ca employees and have workers'
PAY 9. Budding addition
[NO workers' comp. insurance comp. insurance.* Q
yequired:} 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3am a homeowner doing aIlwork officers have e xercised their . 11.0 Plumbing repairs or additions
yself [No workers' comp. right of exemption per MGL 120 Roof repairs .
insurance required.] t � § O�
c. 152 1 4 and we have no • _
employees. No workers' 13.[] Other
comp. insurance_ required. }.
*Any applicant that checks box #I must also fill out the section belowshowing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contra Lw. must submit a new affidavit indicating such.
tContractors 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. Tf 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/Stafe/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 crimin41 penalties of a
fine up to 51,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investi 'ons of the DIA for insurance coverage verification
I d e reby certify under the pains and penalties of perjury that the information provided above is true and correct.
(
r�.: .e: , ;:� 1 - 1
-
Phone #: C j (3 3 L -- / 7. � � - -
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 • • t Y •
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES •
B r
8.1 Licensed Construction Supervisor: Not Applicabl2 ❑
•
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT .(M O L. .15 , §-25C(
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 ❑
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 State of Massachusetts General Laws Annotated.
Homeowner Signature i 414-1,1 \) / / Z�
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Acc `sory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [p] Other [0]
Br ief Description of Proposed ' , .
Work: • r , , di/ ✓
Alteration of existing bedroom Yes No Addi g new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
r" , a7? . e ai r t n •ey m s ® 4 iA®, " a >u�. �'._..' .
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 construccfibn
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. Wih:<building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION la.; OWNER AU hORIZATIQN 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
1 , 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.
6 - Vic &A6
Print me
dill Ii \ s` . Cl- ‘1,9g1i1
Signature of Owner /A -, ent Date
.,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomp Information. _ .. i
Existing Proposed Required 1 ' Zo I
This column to be filled 4 u
Building Detriment !
Lot Size I z
.a�
Frontage l I
Setbacks Front •
Side L:1 R:' L:I , R:( I 1= i._..__i
Rear I . 1 I
Building Height 1 1
Bldg. Square Footage 1 f 1% 1 1 1
__Open. Space- Footage %
(Lot area minus bldg & paved J li € 1 t
ping)
# of Parking Spaces
I t
Fill:
(volume & Location) t t
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page I and /or Document #1 I
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: I
D. Are there any proposed changes to or . additions. of signs. intended for the property ? YES i NO 0
IF YES, describe size, type and location:
i
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 O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
-E EtVED c, of Northampton
B 'Iding Department 1
a � 12 Main Street g $F �q i R
al 2 Room 100 .�`���� t
► • rt - mpton, MA 01060 �� ,, fs ' � , '€t � ' � .,.
' p pF sumo ;� .7 - : r -1240 Fax 413 -587 -1272 � � 3, '
woatrw�� �� �; ,.,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
I 1.1
Property Address:
CTION 1 - SITE INFORMATION
This section to be completed b office
P R
' a � � `" x ' � Lot ��' Utn
N 1 C∎hy (1'1 F C `L ii; C) Z " a verla )is
EIm Std tdcC C
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: {\ ( �r c i v 1 01-41d p 4 ; .1 /}
19 \ � �" �{ i � c' 1 -? ► \j 6 - 1 t ; OA,� 1 �1.1 - ) D : 1 U - .
Name (Print) ` Current Mailing Address:
6 (to (_i ), 6�-
-- Telephone Li I ✓3 cS _ 1 a
\, ___.-Signature
y
2.2 Authorized gent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 : C
ESTIMATED CONSTRUCTIONOSTS .
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Penntit Fee
V
2. Electrical (b) Estimated Totat 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 7 /
Th is S ection For Offic Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /inspector of Buildings - • • Date
39 RIDGEWOOD TER BP- 2011 -1108
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A - 062 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP- 2011 -1108
Project # JS- 2011- 001784
Est. Cost:
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 5488.56 Owner: BORGOS JOAN E
Zoning: URB(100)/ Applicant: BORGOS JOAN E
AT: 39 RIDGEWOOD TER
Applicant Address: Phone: Insurance:
23 N BEARS DEN DR (413) 348 -1723 ()
SUNDERLANDMA01375 ISSUED ON:6/29/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: ST RI P & SHINGLE 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 6/29/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner