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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 hone 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
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
Cf"L:5
I, understand the above.
(Home owner /residen s signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to the:
Date /// 5/1 /
Address of work f4v location 2 5 - r. 5A
Ak2,-- o /G6c)
,
. . ,
' n
The Commonwealth of Massachusetts
.... ,==r .... ....7 , . Department of Industrial Accidents
Office ofinvestig,ationS
. .......,.., ...- .
600 Washington Street
T . =4,1_=...... ..!
el 7 ,Z Boston, MA 02111
„ -.---
www.mass crov/dia
• -b
..:..
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
-.,-.
Applicant Information • Please Print Legiblv
:...=. : .
Name (Busines.i/Organilationandividiral): /7 //) ca
- Address: 2 z..c Arc c / $ -) 5 0:.( a L i i-- .. -
m 0 c - re'7..)
City/State/Zip ...10 Jur 6 I .dit- f 'f t (06° Phone.#: 4- 0 3 -.'..) / ...., 73 7-/
Are you an employer? Check the appropriatehox: • . Type of project (required): /
1.0 I am a employer with 4. 0 I am a general contractor and I
6. 0 New coistruCtion
have hired the sub-ccnitractors
employees (full and/or part-time).*
listed on the attached sheet 7. 0 Aemodeling
2.0 I am a sole proprietor or partner-
ship ;Ktd..have no employees These sub-contractors have. -8. 0 Deinblition .
- working for me in • any capacity. igoployeesandliave workers' : -_.. ,-. ._ -, •
9: 1:113thldMradition
5 0 We a id a corporation an d it 10.0 Electrical repairs or additions
required.] - . • __,
3"...I am a homeowner doing all work officers haire4xerreised their
0 -1 • 11. Plunibiog repairs or additions .
myself. [No workers' comp. - right of exemption per MGL r—r
12.0 Roof repairs . •
i nsura n ce requ t • : c. 152, § 1(4), and we have no • Other ,
13 1:1 . , •
einployees: [No workers' 13
, -
' ' • . comp. insinmice requited].
*My applicant that checks box #1 must also Ell out the section below showing theirworkers compensation policy informatien. . . •,-, .
t Homeownera who submit this affidavit inrag they are doing all work and then hire outside txmtraitori must submit a new affidavit indicating such.
:contractors that chi-A this box mustanached an additional sheet showing the name of the subcontractors and Site wile:titer-or notthose entities have •
employees. If the sub-contraitorshaie employeeS, they must provide their wthkeis' comp. Poky number.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policyand job site
information.
- .
Insurance Company Name: - .
. . .
Policy # or Self-MS. Lic. # - Expiration Date:
. - .
lob Site Address: : - :. City/Statm/Zip:' - - - - - -
Attach a copy of the workers'' compensation policy declaration page the policy nurnber and expiration date).
. .... .... - _ .. ....,
Failure to secure Coverage . as reqUifediiii&i: Secti6 h 152 can lead th the iiiiiiiiiiiiiii iifaiin of a
fine up to 51,500.00 and/or one-year irivisonment as well as civil penalties in the form of a STOP WORK-ORDER and a fine
of up tir S250.00 a 4,4j against the yiolatif. Be adviSed that a copyof this statement may be fo rwarde d to ii.Ciiriceof
'E* cif the pricfoiiiiii . -
Ido hereb_y cerai under the' ‘ • - , alties ofperitay that the infonnalIonprovtdedaboveis_true• _and_corrPet
Siena Hi. . /
.....- e,/
ei — : 7 : : • i5at: ,.?. 0 • . ,
Phone #: • 1 // 3 -- ' , , V .'.' 7 3 -- 7X - f .. : " ' . ' • - 1 • •
. - Official use only Do not write us this area, to be completed by city or toWnofficiaL
. .
City or Town: '• Permit/IAcense # '
Issuing Authority (circle one):
:1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector
6. Other ,
Contact Person: Phone #:
4
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ , AW . 48
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
TE -..... 1 ... _.._.. Not Applicable Ik�Revis#enid.Horne tmpi'o�etrier� Cori�actor,,,,� � ._...�:���,� �,�,�� ,�.,.� = ❑
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 ❑
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 r- . 5onsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning La . d State of Massachusetts General Laws Annotated.
' •
Homeowner Sign, �. ��;. _ / ��
/ purr
,
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition El New Signs [D] Decks [ Siding [0] Other [D]
Brief Description of Proposed nn / t C J
Work: !l C., c( n) 12k €1 c -' /�I .5
Alteration of existing bedroom Yes No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes i� No
Plans Attached Roll - Sheet
e. ' tf I+te4;Ftous Nand fariit ttifij'ii iisinct: c ampie e:t re fdtio iu np:
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 !- OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS, AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Oa [J) ,1 6YO :Cf_ as Owner of the subject
property ,
hereby authorize 1 L../, d. ,
to act on my behalf, i'T't'all matters rel 've to work`authorized by this building permit application.
Signature of Owner Date
I, ,') t t/l,0 6 Lz--, c /A , 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.
./.. U/ d 6 0 //-\-.
Print Name
1
�- - -__ `//2 5// /
Sign- - e of Owner /Agent/ Date
• •
WA Al W t
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete for tion
Existing Proposed Required by Z • 60
This column to be . by
Building Departm. ,
rr
' Lot Size 1 5 . J7 � I i s �i l £ £
J 5
Frontage - .
Setbacks Front W171 ZEE I
Side L:1 I R:l )5 ? L:i "s 1 R:1 i $
Rear
Building Height ;----- r I
E t
Bldg. Square Footage "` % --I [
Open Space Footage g . %
(Lot area minus bldg & paved ?
parking)
# of Parking Spaces I I I —
Fill: i.� I 1_. _�
(volume & Location) ,
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES 0
i
IF YES, date issued:I ?
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW 0 YES 0
IF YES: enter Book Pagel F 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 ® Obtained ,Date Issued
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location: I - }
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO e
i
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 Aa
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
4
I.
r
A
City of Northampton e
Building Department 1 , r1
212 Main Street a , t s
Room 100 s
{' Vortham ton MA 01060 a
_ • • - ' 3- 587 -1240 Fax 413- 587 -1272 k
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
Map °;, Lot Unit
)c5
2 Q ,(` J L- C T .,S r7 E C l Z one gverlay Drstrict
2
Elm St District CB. District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
a vi / 2 6 ct, "--t z z a / i t) c 574-
Name • !nt) Current Mailing g, y
�f_•- �� 4 ' I Telephone
J Adddress: -- ' 3 �
g nature / r
2.2 Authorized Agent.
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
tir (a) Building Permit Fee
1. Building
/00
2. Electrical (b) Estimated! Total Cost of
Construction from, (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) 351
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) / 000,C'C ) Check Number go .
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0833
APPLICANT /CONTACT PERSON GLOMAN DAVID I & KATHERINE E SCHNEIDER
ADDRESS /PHONE 220 PROSPECT ST NORTHAMPTON Ok
.
PROPERTY LOCATION 220 PROSPECT ST e(- 1,40 IT p�
V tC-
MAP 24D PARCEL 231 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fep-Paid
''Belding Permit Filled out `-�
'Pee Paid T >0 . UC3 36 I
Typeof Construction:_6x10 Deck
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
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
D,-molition Delay
Signature of Building Of icial 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.
220 PROSPECT ST BP- 2011 -0833
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 231 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit # BP- 2011 -0833
Project # JS- 2011- 001377
Est. Cost:
LJL. u
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 5662.80 Owner: GLOMAN DAVID I & KATHERINE E SCHNEIDER
Zoning:URB(1001/ Applicant: GLOMAN DAVID I & KATHERINE E SCHNEIDER
AT: 220 PROSPECT ST
Applicant Address: Phone: Insurance:
220 PROSPECT ST
NORTHAMPTONMA01060 ISSUED ON ::4/22/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:6x10 Deck
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: , t 4 (
Final: Final: C ,
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: 0r ' 6 r ? - ` ( A"—
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REG • 0 S
Certificate of Occupan , nature: 47°P * 15414 tzetii-c4
FeeType: Date Paid: Amount:
Building $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck – Building Commissioner