24B-080 (3) 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, act as their ownrconstrnefion 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
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
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
.-t.. t/a understand the above.
(Home owji r /resident ignature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date i d 1 7 1 (
Address of work 0
location s 6 ►rtici -a,.J S .
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• The Commonwealth ofMassachusetts
F - Department of Industri al Accidents • ,
=�-� — ' Office of Investigations • •
_ = i — }� T.
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d,!... _ 600 Washington Street
Boston, MA 02111
• `•••. : , www.mass gov /dia •
• Workers' Compensation Insurance Affidavit Builders/ Contractors /Electricians/Plumbers - ..
Applicant Information - Please Print Leiibly
Name ( Business /Organization/Iadividm1): /1/1 4 W Vc`i v i -et�)
- • Address: C b diy 1 s A- • / ,J
•
C i t y / S t a t e / Z i p : NoillAttoytevi i AM b i 6 b I Phone. #: Lfl 3-3.2-0 32..O/O33 • -
Are you an employer? Check the appropriate'box: . •Type of project (required):, /
.. am 'a general contractor and I
1. ❑ I am a employer with 4 ❑ I a g 6. 0 New cmistruction
employees (full and/or part-time). hired the sub - contractors
2.0 I am a 'sole proprietor or partner- listed on- theattached sheet: 7. O. Remodeling
• ship and have no employees .. These sub - contractors have. s. 0 Demolition . .
• working for - me in an Io_yees-and:js workers' -
y t3' i,nrna„ee #: 9: u❑ l i mg arl •
(14o• workers- comp: insurance 10. IIectricat additions .
j 5. ❑. We are a corporation and its ❑ c rep airs or ad
• 3 . I am a homeowner doing all work officers baverercised their 11.0 Pinmbing repairs or additions
myself [No workers' comp. -t of exemption per MGL 12.0 Roof • insurance required.] t ' c: 152, §1(4), and we have no • . . •
emplo [No workers' 13 Other S t 4 1 : K1
comp. isivancr ed
• *Any applicant-Mal checl6.boxit: most, also fiII motile section below showing theawa± en '- compensation policy infmaation_ ' - .
t Homeowners who submit this afdavit:indicating they are deluge! work and then has outside contras must submit anew affidavit mdicatmg such zcontractors that check this box mristattached an additional abed showing the name of the subcontractors and state whether-or not -those entities have -
employees. 'If the sub- ccamactors have employe, they must provide their ' comp- po1cy numb -
J 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: C /Sta .
:.
?ty trlZip:
Attach a copy of the workers' :compensation_ p declaration page'(showing t pphcy number a nd _ex iration date).
Failure to secure coverag as required nnder.Sea 25A ofMIGL : can Ieadto the of. penalties of
fine up to $ I,500.00 and/or one- year as well as civil penalties in the form ofa STOP WORK-- 0..RDER and a fine
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of up to S250.00 a day against the violator Be advised that a copy of this statement may be forwarded:to the Office of ;.:
Tnvesttsations ofthe DIA for insurance cover venfcatuoa ... , .. _. ....
t
do her _ _ "'t p ains -anal pena c
lties . f perjrtry hat the &fermatin n prow de dsrbave rstrrre r a rrecd ' u
_ I
Si ature: r
m bate: r 7 I' 1 _ ,
� _ ! t. - _- 1.7-.o
Phone .4013 .
#: . ..
- Official use only. Do not write iir this area, to be completed by city or townoffcial
City or Town: . - • Permit/License #
Issuing Authority (circle one):
:1. Board of Health 2. Building Department 3. City/Town Clerk 4. Eleetrical,Inspector 5. Plumbing Inspector
6.Other -
Contact Person: Phone #:.
p' Y'
7: n
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9� ReOlstered Horne Improvement 0ontractort, 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 ❑ No ❑
11 . owe Owner,Exemption
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 arfdocal ZonirLaws and State of Massachusetts General Laws Annotated.
Homeowner Signature � , j
f
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [] Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[l Siding [m] Other [CI]
Brief Description of Proposed
Work: take down and put up cedar siding and paint
Alteration of existing bedroom Yes nO No Adding new bedroom Yes tlO No
Attached Narrative Renovating unfinished basement Yes n ° No
Plans Attached Roll - Sheet
6ar . f New, a s:, and a . ®« l nv :xi 1 } _h .us L ° C. t = A a fall a win r :
a. Use of building : One Family yes Two Family Other
b. Number of rooms in each family unit: 5 Number of Bathrooms 1
c. Is there a garage attached? no
d. Proposed Square footage of new construction. n/a 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 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 Budding 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, , 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
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 under the pains and penalties of perjury.
i / 2 ("at( '
Pr t Name
r ,
i
Sig •lure of, e r [ Date
ikihh.
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 .23 acres
Frontage
Setbacks Front
Side L: R: L: _ R:,
Rear
Building Height % l
Bldg. Square Footage I 0
Open Space Footage �
(Lot area minus bldg & paved
parking)
# of Parking Spaces 3
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued: 09/30/2009
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book 10034 Page! 25 and /or Document # 00029125
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
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 (3
IF YES, describe size, type and location: ';there will be a l' by 1' sign on the back building
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location: see above
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
lee - 7 !
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• � r t City of Northampton r
uilding Department 4gi � k ; ,' 7 k ,,
1qq‘ 212 Main Street - . fi k ` a ,g '6A N gg
Room 100 ,
u,.. • hampton, MA 01060 ; .., ; 0 0 „,v16 ov
r . :ne 413 - 587 -1240 Fax 413 - 587 -1272 � i , `�'� 4 � a`i , - ' Y t s
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
51O 0/401 1 p A sr Map Lot Unit
Nc (t16. 1t-'Y1 , 44 A Zone Overlay District
Sim St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Meg Largey 56 Bradford St. Northampton, MA 001060
Name (Print) Current Mailing Address: 413 - 320 -1083
Telephone
Signature N\
2.2 Authorized Anent:
187 Hope St. Greenfield, MA 187 Hope St. Greenfield, MA
Name (Print) Current Mailing Address:
187 Hope St. Greenfield, MA
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 3,000 (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) 3,000 Check Number 0 70 J ..--
This Section For Official Use Only
Permit Number: Date
Building Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
56 BRADFORD ST BP- 2011 -0806
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24B - 080 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Siding BUILDING PERMIT
Permit # BP- 2011 -0806
Project # JS- 2011- 001326
Est, Cost: $3000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(s 10149.48 Owner: LARGEY MEG & CATHERINE JENNINGS
Zoning: GI(100)/ Applicant: LARGEY MEG & CA1 HERii' E SENNING3
AT: 56 BRADFORD ST
Applicant Address: Phone: Insurance:
56 BRADFORD ST
NORTHAMPTONMA01060 ISSUED ON :4/7/2011 0:00:00
TO PERFORM THE FOLLOWING WORK :INSTALL CEDAR 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: CO_;: T•c»lition:
Final: Smoke: Final: Qv ' 5-9-I ((Wk.
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULAT q S.
/'` � 1,.4:, , Lt2 ft‘th'
Certificate of Occupanc .-- ....! signature:
FeeType: Date Paid: Amount:
Building 4/7/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner