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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
— conceatedVinsulation - inspectionlifreeuired) - and - a - final - building - hispection. 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
jermits 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
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.
Date
Address of work
location
, -
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, PIA 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print egiblv
Name pusinesiforganizationadivithi.D: ..... AN a A 1, A_ • ..A. A.2.)■
Address: (Alea 197
P—(4- • ,
City/State/Zip: Fit, 44A (71060)hone #:
Are you an employer? Check the appropriate box: Type of pi (required): /
1.0 I am a employer with 4• 0 I am a general contractor and I
6. 'N
ew construction
have hired the sub-contractors
employees (full and/or part-time).*
2.. Pi I &in a sole proprietor or partner- listed on the attached sheet 7. KRemodeling
These sub-contractors have.
".• and have no e.wloyees 8. 0 Demolition
enployees have workers' .
working for me in any capacity. 9: 0 Building naditiOn
[No workers' comp. insurance _ corop..insiirp-nre
required.] 5. 0 We are a corporation and its 100 Electrical repairs or additions
3. I am a homeowner doing all work officers haVe4xercised their
11.0 Pluinbing 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
• ecs o • • • .4
comp. insurance required.'
*Any applicant-that checks x#1nazst also fill out the section below showing their workers' compensation policy information.
t Homeowneri :who submit this affidavit indicating they are doing all work and then hire outside contactors must submit an affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub and state whether or not those entities have
employees. If the sub-contraCtors haVe employees, they must provide their workers' comp. policy number.
am an employer that is providing workers' compensation insurance for my einployees. Below Ls the policy and job site
information.
Insurance Company Name: •
Policy # or Self-Ms. Lic. #: Expiration Date:
Job Site Address: City/StateiZip:' -
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requited tinder Seetiiiii 152 can lead to the thzposition of crib:dna) penalties of a
line 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 ate
of up to $250.00 a day against tiM violator Be advised that a. copy of this stateinent may be forwarded to the OffiCe of
eItiations �f the DIA for insurance coveraae veriflcition.
_ dd hereby certify tin the enalties the informanonpron d e d _above _androrre
_ .
Signature: ,6(
Date : 2 (C2
Official use only. Do not write in this area, to be completed by city or town off/cirri
City or Town: Permit/License #
Issuing Authority (circle one):
:1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricaLlnspector 5. Plumbing Inspector
6. Other fr
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction S , /� �^ ,� Not Applicable ❑
Name of License Holder : ' jZ\J ¶ 3 , cc ` Cir c I'1 (Z (f
ir? License Number
I
Address Expiration Date
5 —
Signat re Telephone
IL:- 01,u, ' `w p mizazu, Not Applicable ❑
Lae a-cz)R4tk f• ( o 2 t 6
Company Name Registration umb r
/ZE, 1z ��
Address ��f *� Expiration Date
Fi cAR (/\ 4 4 Telephone .� -1 cE
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 X 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 buildine 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
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) i►A4 Roofing ❑
Or Doors ❑
Accessory Bldg. El Demolition El New Signs [O] Decks [E ] Siding [O] Other ED]
Brief Description of Proposed 1
, ` FzerP , 4 �r1/i et `"�'�!
Work: (,^
Alteration of existing bedroom Yes K No Adding new bedroom Yes N Sd.1
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Rol( - Sheet
8a Cf t oii 6>` it stir ` wraatl fti aititti'iid166 ifetT 1i` f a fSif Q , s
a. Use of building : One Family K Two Family Other
b. Number of rooms in each family unit: 8 Number of Bathrooms (
c. Is there a garage attached ? - - T , W. -" 1 i
d. Proposed Square footage of new construction. Dimensions 6 )(. to
e. Number of stories?
f. Method of heating? 4,..t/vN, Fireplaces or Woodstoves /\,) 0 Number of eac
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? y4 A
h. Type of construction CA. )—F i
i. Is construction within 100 ft. of wetlands? Yes k No. Is construction within 100 yr. floodplain Yes K No
j. Depth of basement or cellar floor below finished grade ,
k. Will building conform to the Building and Zoning regulations? X Yes No .
I. Septic Tank City Sewer - Private well City water Supply V
SECTION Ta - OWNER AUTHORIZATION - TO BE. COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, ■/ �C i , as Owner of the subject
property �/�
hereby authorize i a _ /4 TAJ d.De�
to act on my�= a in all m rs relative work authorized by this building permit application.
s ature of Owner -
e _ I �.__ \ Date 6 - _ 1
1, �iffireltal i _ I , 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 un. - the p ins and pealtes of p
Print Name
�� Ci 0
Signature of Owner /Ag='t ' Date
w
W
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 f ? \ QCfi-) 1 a � ..� I -t
Frontage
• �t" C 1 ,
Setbacks Front 351 I
1
Side L: R: L: R:254 i
t
Rear
Building Height V;1' i
Bldg. Square Footage Ts] L
Open Space Footage % �� ]
(Lot area minus bldg & paved 4 '
parking)
# of Parking Spaces I 1 4 I -
Fill:_ _ . � ._._ ,
1.
(volume & Location) t ,
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW � .. YES 0
IF YES, date issued:
1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW ® YES 0
IF YES: enter Book I ! Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 411 DONT KNOW 0 YES Q
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 ga
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 ►7"
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 04
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
A
City of Northampton
Building Department t a
212 Main Street
%� i� - LO10 Room 100 r E . ::,: s ,�� _
3 No hampton, MA 01060 � ,
phone 41387 -1240 Fax 413 - 587 -1272 R
---��
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„.5 -- �VV 1 S� Map Lot Unit
1\k)J--llANNNIO-1-0/1/\done : Overlay District
Elm St District - CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Q _ 4- 141 S - o,wleS *----�� L evy 1.,, ,Lvto
Name (Print) . , / Current ng Addre s /\
..
At / / / _.- Telephone -+tom o
2.2 A rized A ent• i
)4 )- 4 - CIA ` \ 1 bk,ii)� \ x (4-19 r a
Name (Print Current Mailing Address:
V .- Zk- Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
,r by permit applicant
1. Building + 10 _ (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) I I Check Number ! t
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/lnspector of Buildings;,
.` Date
File # BP- 2010 -1103
APPLICANT /CONTACT PERSON PAUL MCCUTCHEON
ADDRESS/PHONE 1526 WESTHAMPTON RD FLORENCE (413) 584 -3352 O
PROPERTY LOCATION 25 BARRETT ST
MAP 24B PARCEL 026 001 ZONE HB(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 79‘)E #5
Typeof Construction: CON .&RUCT ROOF OVER 6 X 10 PORCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 062544
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF5 MATION PRESENTED:
V 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
C l / iopo
Signature of Bui ding 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.
25 BARRETT ST BP-2010-1103
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24B - 026 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 -1103
Project # JS- 2010- 001621
Est. Cost: $1250.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL MCCUTCHEON 062544
Lot Size(sq. t): 18600.12 Owner: SQUIRES JOSEPH D & MICHELLE L
Zoning: HB(100)/ Applicant: PAUL MCCUTCHEON
AT: : 25 BARRETT ST
Applicant Address: Phone: Insurance:
1526 WESTHAMPTON RD (413) 584 -3352 0
FLORENCEMA01062 ISSUED ON:6/10/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: CONSTRUCT ROOF OVER 6 X 10 PORCH
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: j.1v;,eS nK 4240
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: DIG b 1 id
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
( 4444:. /4.4.4.4
Certificate of Occupancy CI ?w I is t-eflovz ki l.Signature:
FeeType: Date Paid: Amount:
Building 6/10/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo