24D-240 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
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
1, 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
r
. The Commonwealth of Massachusetts
;_.— Department of Industrial Accidents
= - of •
G r 600 Washington Street
( Boston, MA 01111
,,... - , www.mass g ov/dia
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business / Organization /Indivirinat) ie i" ('4�■ c• - 4 e C p4) c .-(' - .., r , C4 0/•- ,
Address: l!" 44,e e-X: // / .
City /State/Zip: A i 7 Ave - C' , ' ge' 7 Phone. #: 4 1/ V 2: 4''/ 7 1
Are you an employer? Check the appropriate box: Type of project (required): /
1.0 I am a y lo_ er with - 4. 0 I am a general contractor and I
6. 0 New construction
employees (full and/or part time).* have hired the sub- contractors
2. .0 I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling
• ship and have no employees These sub - contractors have. .8. 0 Demolition
working for in any capacity. employees and have workers' 9 0 Minding aAdition
[No workers comp. insurance - ins"ra
required. 5. We are a corporation and its 10 0 Electrical repairs or additions
] .
3.0 I am a homeowner doing all work officers havexercised their . 11.0 Plumbing 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
employees. [No workers' 13.0 Other
- comp. insurance requiired.].
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.
: 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 required udder Section'25A'ofMGL c 152 can lead to the nnposition of cnivma1 penalties of a
fine up to $1500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER_ and a fire
of up to $250.00 a day against the violator Be advised that a copy of this statement maybe forwarded to the Office of
Eivesti tions` t he DIA for insurance` coverage verification. _ , _,.
/do hereby certifyy der the pains and penalties of perjury that the information provided_ab' ors u a - _ • Signature:- Date: ,
Phone #: Q/ ,7 �i `e. 7 ,f 1 : - .. .
Official use only. Do not write in this area, to be comp1PtPd by city or town of iciaL
City or Town: Permit/License #
Issuing Authority (circle one):
.'1. Board of Health 2. Building Department 3. City/Town Clerk . 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construct! p ��rrN isor: Not Applicable ❑
•
Name of License Holder : g�- � ' d'`�r° C---%. i N ;+ I 1 ( ' J 1c/5
License Number
� �` � ii i Am' % r / /'/ e/ z-
Address Expiration Date
A L-- 4. - q / . 7 t v/ 7.1`
Signature Telephone
S. Rettistere triess imriro remert +Qntractar . _ : _ r^ .. �E ge .. Not Applicable ❑
le t d 44 CC-,. 1 `: •..✓Z. v . i _- / / r
Com nv Na m e Registration Number
/f' � n:` ij `rte/ .-/
Address Expiration Date
A*,,Lii .1411 Telephone) /i ( 4Y4S 7l,7 `
—
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 452, § 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 ❑
1 on on
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 shelf 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House EJ Addition ❑ Replacement W lows Alteration(s) ❑ Roofing D
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [(_J Siding [D] Other [D]
Brief Description of Proposed
Work: / ZE,. 9' 44 -' t ' Z..t -.( 74,: /t.
Alteration of existing bedroom Yes No Adding new bedroom Yes l4''' No
Attached Narrative Renovating unfinished basement Yes 1 / No
Plans Attached Roll - Sheet
so Hof a .hoes` wind 6ridd Panto a ai O J rii iefe. ire° tilkii hWii
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
1. 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, i 4AtDl `.
as Owner of the subject
property
a*. hereby authorize
to act on y beh , ir maths relative to work authorized by this building permit application.
Signature of Owner ',•,(`,JJ Date
I, ` �' �''./ ` r 4J a 0 "� r , 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.
Sig er the pains and penalties of perjury.
•
Print Name
(-- -___ :y of....a...._____ _
„...40.4.--- VA ' 9 ////
Signature of Owner /Agent Date
./.(//42' . *'' .
/ C P ,
Section 4. ZONING Alt Information Must Be Complett. Permit Can Be Denied Due To Inco ete 1 formation'
Existing I Proposed Requi y nir • '
This co t filled in
! Build
\
' ° 7
.\,.
Lot Size i --• -t-
Frontage f 1i
:'''' ., /
Setbacks Front 3 s E " '*
Side L:!
1-7 R L:1 _.. R:� . _ _ ,i t 9
Rear ___._
Building Hei ' - - 1 r
Bldg. Square Footage r--I I 1% 1 1 1 f
. Open Space Footage
(Lot area minus bldg & paved 1 1 1 1
i 7 r
,, .
parking)
# of Parking Spaces i -
Fill: 1
(volume & Location) [
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 o. Deeds?
NO 0 DONT KNOW 0 YES Q
I IF YES: enter Book Page: I and /or Document # mm ^
B. Does the site contain a brook, body of water or w tlands? NO Q DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtainJd from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued
C. Do any signs exist on the property? YES 0 NO 0
i
IF YES, describe size, type and location: •
D. Are there any proposed changes to or additions of J ins 0 NO '
intended for the property ? YES 0
IF YES, describe size, type and location:
s
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 ermit from the DPW is required.
•
City of Northampton - r
0 ► Ming Department
2 Main Street E ®� 3,
oom 100 ®, {
�" �- ampton, MA 01060
- 587 -1240 Fax 413- 587 -1272
• sr - • TION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map Lot .. Unit
;Zane " Overlay Distrac
Elm St °Dtstrlct CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: /l C
Name rint) Current Mailing Address: J r
..ter gee-41
Telephone
Signature
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
1. Building (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) Check Number Fc/ i3
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
97 CRESCENT ST BP-2011-0884
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 240 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit # BP-2011-0884
Project # JS- 2011- 001442
Est. Cost: $9000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID CHICOINE 061582
Lot Size(sq. ft.): 12109.68 Owner: FELD EDWARD & MERLE L
Zoning: URC(100)/ Applicant: DAVID CHICOINE
A L: 97 C RE..CE:bi ST
Applicant Address: Phone: Insurance:
16 EDGE HILL PLACE (413) 246 -7536
AMHERSTMA01002 ISSUED ON :5/2/2011 0 :00 :00
TO PERFORM THE FOLLOWING WORK :INSTALL REPLACEMENT WINDOWS
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 Frailf
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: O/ j -- '--(f e_/C//t/k,
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND ' ■ 0 1 k .
/Kef - 4
4 1:04. 4 * lleAkoit4•4
Certificate of Occupanc, -•-' - _ Signatures
FeeType: Date Paid: Amount:
Building 5/2/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building C ommissioner