24D-118 c
f d
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 woik at various stages, wluc in tins (before baekfl).
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
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 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 i1 require ilding inspections necessary for the building permit
issued to me.
Date
Address of work
location
ti
',, The Commonwealth of Massachusetts
Department of Industrial Accidents '
t '� Office Of Investigations
600 Washin Street
.=_,. w Boston, MA 02111
v Ems `= www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly •
Name ( Business /Organization/Individual): 1
Address: t- \�X l O 01/41:4AW
City /State /Zip: $‘41. W1/4. Z AZ o Phone #: + - bZ--5 —4111
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction
2X I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. El Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have 11_ Plumbing repairs or additions exercised their
3. ❑ i am a homeowner-doing-all-work - -- - --
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
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 must 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. Lic. #: 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 as 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 on yearimprisonment, well-as civil penalties -in- the form of -a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do her Ira' -'- .wider the pains and penalties of perjury that the information provided abo e is true and correct.
S ignature: t � Date: b •
Phone #: AVC w tt o \
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. Beard- trf- Fleal-th -2. Building-Department. 3. City/To wu Cleik_ 4_Jlkc_trical Inspector 5. Plumb ing Inspector
6. Other
Contact Person: Phone #:
/ 4
r - '
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
,
Name of License Holder : l Ph(1'� \.-.-A" CS TT 4
License Numb r
_ . -4. ‘ilo
�..,•,.. Expiration Da
.�� A - b 2 c' Vtlq
Signat ' - Telephone
9. % gistered.Home improvement- Contra q for ,,, < Applicable ❑
‘4 - - NS M / tOLC � Vct 1,a1
Com
l
any Name Registr ion umber
.6c3ox LjNSVc�1���R.Oto I it, la
Address Expirati Da e
Telephonel3 — bQ Q`Q J
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG.L. c. 152, -§ 25C(6))
Workers Compensation Insurance affidavit t be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildi permit.
Signed Affidavit Attached Yes No ❑
1 ., I3cimre.t; s 0 < e 4 emip a+ >a
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- i -ssued
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 to of Massachusetts General -Laws Annotated.
Homeowner Signature
\v
,
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
.
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
�- / Or Doors 0
Accessory Bldg. ❑ Demolition LJ New Signs [D] Decks [0 Siding [DJ Other [❑]
Brief De criptiovQ of Propo ed 1 - (� CA
Work: " A K, k. 60u) v.) et.% W - DKik !i 1 �,1 A�` O tt. Ut V! O.) L%1\' tk �r AOC/1 (6.4N `Nn(R t1
Alteration of existing bedroom Yes 1 V No Adding new bedroom Yes r e---e- No
Attached Narrative Renovating unfinished basement Yes V No
Plans Attached Roll - Sheet
6a:if New house-and or addition taexistina housing; com le"te the ,follevtr nq:
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 - iOWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, sT)„ , as Owner of the subject
property M
hereby authorize ` ,
to act on m be�, in all matters relativ authorized by this building permit application.
G
Signature of wner Date
1, re {k11( , as
9 y atements and information on the fore
A ent h declare that the foregoing application are true and accurate, to the best of my knowledge
g
and belief.
Sign • under the pains and penalties of perjury.
Pri i i_►
A r ..
_ � 111" —
r i9,n e . •, - - 'gent ate
1
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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
Frontage �.....
Setbacks Front
Side L... _.._ . _. R::._, ._ _. L:i
Rear
Building Height
Bldg. Square Footage % 1
Open Space Footage
(Lot area minus bldg & paged ,
parking)
# of Parking Spaces i I
�._q _
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Findin ver been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Regi ry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page;` and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 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 0 , Date issued:
C. Do any signs exist on the property? YES C) NO e .. _
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property y p p g g p perty? YES 0 NO
IF YES, describe size, type and location:
E Will the construction activity disturb (clearing, grading, exc ation, or filling) over 1 acre or is it part of a common plan
that wit disturb over 1 acre? YES O NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
■ • ti ,
N.
Depaitment use only
City of Northampton Status: of Permit
Building Department Curb,Cut/Dnvewa(Pe i t ` ....
212 Main Street Sewer /Septic Avarlabd ty
Room 100 Water/Well Av
Northampton, MA 01060 Two.Sets of Structura!Plans
phone 413 -587 -1240 Fax 413- 587 -1272 PiotISite Plans _ .
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING .
SECTION 1 - SITE INFORMATION
1.1Property Address:
This section to be completed by office
k i � C_' f(.` �\'(C'4 S t Map Lot Unit
\V CI l ^k � %'' % 6 ` L° Zone Overlay District
Elm St. District _ CB District
I
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT -I
1
2. caner of ecord:
\ c
Name (Print) Current Maii[ni Address t-{-1-
C Telephone
Signature
2.2 Authorized Agent:
Pik '�' tO ( 111 'iSh,4kkA f Vktss, 6 \130
Current Mailing Address:
"" 44‘7, —1)2-s 6gckq
Signatur- Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Rem Estimated- Cost - (Dollars) -to -be Official Use Only
completed by permit applicant
1. Building 415 (a) Building Permit Fee
2. Electrical 2,460 (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) b 0(3 Check Number
"This Sectio 'FO Official'Use •Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings - Date
11 ilA NAT BP- 2010 -0066
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: RENO WIRING BUILDING PERMIT
Permit # BP- 2010 -0066
Project # JS- 2009 - 001551
Est. Cost: $7600.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANDY 077431
Lot Size(sq. ft.): 7100.28 Owner: FOWSKI KIM CIO RACHEL HANNAH
Zoning: URB(100)/ Applicant: MARK LANDY
AT: 11 CHURCH ST
Applicant Address: Phone: Insurance:
P 0 BOX 61 (413) 625 -6999 ()
ASHFIELDMA01330 - 0061 ISSUED ON:7/20/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INTERIOR RENOVATIONS REMOVE NON
BEARING WALL TO ENLARGE KITCHEN
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:
14 / /
Building 7/20/2009 0:00:00 $0.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo