24D-037 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 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
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
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
Date
Address of work
location
,
, ,..
., .,
•
. .\ The Commonwealth of Massachusetts
Department of Industrial ACcidents
Office of Investigation&
r azz 5 600 Washington Street
Boston, MA 02111
www.mass aov/dia
....--,,..,
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information • 7 Please Print Legibly • :::
,--- ,
Name (BusinesS/Organization/Individual): . V- 1 1 , . ,;- -- 2. 1 .-- , , ' /
'
/
i 6 i
7 )
; • ., .
. .
• Address: ) (' -- , ..t./ Le 4/ /(. -
. /
City/State/Zip: ,-/ 1 ' r i . - Phone.#: / , 7- , 4 - -
IMIMIIIIMI'll'll
il
Are you an employer? Check the appropriate box: • . 'Type of project (required): 1 "
1.0 I am a employer with 4. 0 I am a general contractor and I
6. 0 New coistruCtion
have hired the sub-contractors
employees (full and/or part-time).*
listed on theaftnrbed sheet 7. 0 Remodeling
IP J-atica. aole proprietor or partner-
These sub-contractors have
ship and. have no employe .8. 0 Deidolidon
enioyees worke rs' - - - _ . - • •
working forme in any capacity 9 fallthldikg adclitiiiri
[No workers' comp-. insurance- - am - - -- ,-- — - -
10.0 Electrical repairs or adrlitions
required.] - . 5. 0 We are a corporation and its
3. 0 I am a homeovvner doing all work officers hairettereised :their .
/ 11.0 Plumbing repairs or additions
myself [No workers' comp. • right Of exemption per MGL
12.0 Roof repairs
insurance required.] t
e: 152, §1(4), and We have no •
'
13.0 Other
employees: [No workers'
1 . • . comp. insitrance
*Any applicant {bat checks box #1 must also fill out the section below showing rworkers' compensation policy information.
I Homeownera who submit this affidairit indicating they are doing all work and then hire outside contraCtors must submit anew affidavit indicating such. .
:Contractors that check this box must attached an arkUtional sheet shoying the name of the subcontractors and State wiether-or nottbose entities have
employees If the sub-contractors haVe employe = they must provide their wciriceis' comp poRcy number.
Tam an employer that is providing workers' compensation insurance for my employees. Below Ls the policyand job site
formation. • .
• " . - -
mance Company Name: •
• - .
7# or Self-ms Lic. #: Expiration Date: - . * • '
. .
e Address: • • :. City/Sta/Zip:' • • -. • - •
a copy of the worker?' compensation policy declaration page (showing the policy nurnfier andexpira.tion date).
. . .
. .
1 secure Coverage as reqiiiredinicter SeCtitin 1526iii. lead t.6' the iiiiiiiiiiii6ii OfCiiiinnilPenalties of a
S1,500.00 and/or one-year imprisonment as well as civil Penalties in the form of a STOP WORK-ORDER and a fine
50.00 a day against the violator Be advised 'that a copy Of this statement may be forwarded to ttid:Officeof
isCif thEDIA toi.tAibraiidg eOirerae venficatroii. . . __ - ..1 :::._ ..r... --.._,_, _ ... .• „, „,_
artifr under the pains,and penaltie the infOnnatiOnprOvidell:aboveds_t itte.:and.iarnart
j(--,
- r
r . / • .. 7 • .
/ • . ._ , .
. _ _ .. . ..
F.y. Do not write in this area, to be completed by city Or town'officlar
' ' ` • .
- .
Permit/License #
(circle one): -
2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector
•
, 1
Phone #:
•
SECTION 8 -- CONSTRUCTION SERVICES
8.1 Licensed Construction S rvisor: Not Applicable ❑
Name of License Holder : r. �'2� (.t� f � ) � ✓Z / �- y e Lber 1 . - --, - Li
--; /� ` i " ' % ' ,? , y ' l / t / <'✓ I — 2( 1 /___
r_
Address t -, --r.,7 t /� Expiration DAe
Signature ■TeIetibone
. 0 - 7 -4) & / S
9 .`Red're4H e1nmtii�o'irenien % tiritractar�"' „ xw , -�,I f �" a Not Applicable ❑
- - ,_ - , --e
Com p a n � i Nh y r ` -" Registration Number
e-t,z-7- -'..7 < 1.--' / / t ,'Z'r'11--'') _ Addres _ Expir tion Da e
S Telephone `4/7
—
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 ❑
In *ion
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
,f^
,
SECTION 5- DESCRIPTION OF PROPOSED`' WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing `a
Or Doors D '
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [O] Other [0]
r,/
Brief Description of Proposed / ' } `
Work: , , '� _ 1 //" � „;,4 / '° -, ,
,- /
Alteration of existing bedroom Yes No Adding kie4v bedroom Yes -N
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa If e ' fise a»da a dditi xdsf s ha"i sin4„ c'aidiiiiii iii iidviiina:
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 Ta OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
r- -1-/; 7/ , as Owner of the subject
f !7
property r
hereby authorize �.�_ a�' "`! '72 -. y ,
to act on my be f, in II matters relative to work � autt io rize by this building permit application.
7
Signature of Owner " Date
' / - � `- C �--- , as Owner /Authorized
Agent hereby deblare that the state ° ntss and information on the foregoing application are true and accurate, to the best of my knowledge
and belief. LI
Signed under the pains and penaltie ury ,- N3 (
Print me •,
Signature S Date
ure of Owner /Agent
F ..
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Infgrmation
Existing Proposed Required by Zo • ng
This column to ■ illed ' by r
a 1
Building Departin A' 7
Lot Size 7
Frontage 1 I 1 f 3
Setbacks Front i ___.
Side L: ! R:7 7 L: _...J R:;
Rear € 1 1 : 1 i
Building Height i i ?
Bldg. Square Footage '_ �- I 1% 1 3 1 1 r F
1 Open Space Footage %
(Lot area minus bldg & paved
parking)
# of Parking Spaces t - ..
Fill: i ; 1
(volume & Location) 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:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book 1 1 Pagel and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q 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 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 Q NO Q
i
IF YES, describe size, type and location: 1 '-
J
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.
togs City of Northampton t , � £
• tI % Building Department = "' ' = *0;44f
• 212 Main Street
Silk , Room 100 '
Northampton, MA 01060 t
se hone 413 - 587 -1240 Fax 413- 587 -1272 g , " s
�•` e, , _ ® mm fold xa
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
r Map Lot Unit
%j -, � 1 -&-- Zone, . Overlay District
Efm St-District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) f Current Mailing Address:
7 ,,,-.7 � Telephone
Signatu
2.2 Authorized Agent: -)— .-- - -
, n
Name (Pr t) Current Mailing Address:
f �4' ..ice
l j 1
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
copleted by permit applicant
1. Building .. (a) Building Permit Fee
i .. - ) I-- L s
2. Electrical I ) I-- " 4 (b) Estimated Total Cost of ,
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection e � � j
6. Total= (1 +2 +3 +4 +5) Check Number )1
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
15 WINTER ST BP- 2011 -1084
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 037 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 -1084
Project # JS- 2011- 001748
Est. Cost: $5000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES ROBERTS 99404
Lot Size(sq. ft.): 9583.20 Owner: MASON STANLEY P & KATHRYN A
Zoning: URB(100)/ Applicant: JAMES ROBERTS
AT: 15 WINTER ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527 -6078
WESTHAMPTONMA01027 ISSUED ON:6/22/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: STRI 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 6/22/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner