31B-121 (2) Y .
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 fantily
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
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 all required building inspections necessary for the building permit
issued to
Date
Address of work
location
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' The Commonwealth of Massachusetts
Department of Industrial Accidents
P I , .. E 7----"- == in EP
Office of I.nvestigations •
600 Washington Street
% --,
lit ....,. .li woo. Boston, MA 02111 .
- .
'''.-- www.mass.gov/dia • _,,
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Workers' Compensation Insurance Affidavit Builders/Contractors/Electrician.s/Plumbers
Applicant Information Please Print Leeiblv
Name (Business/Organization/Individual) : !::,...,VP 4 eA; 4 pAr e e"::,1 "77w ti....... h
• Address: _ " <", 4 1;‘ ,/ / 61At (''' r -
City/State/Zip: "Vt,i4-0/1/ -e,Yoa 7 — Phone.#: E f/S 1 ' 9 ( 7 I 1 i
Are you an employer? Check the appropriate box: Type of projeet (required): ../
1. D I am a employer with 4. 0 I am a general contractor and I
E 0 N e w construction
have hired the sub-contractors
employees (full and/or part-time).*
listed on the attached sheet. 7. laCtemodeling
2. 0 I am a sole proprietor or partner-
These sub-contractors have
shin and. have no elloyees •8. 0 Deirmlidon
• working for me in any capacity . eral:do ees and have -workers' 9 „. _f-,-, z — un - ....,,e addrti
Q ci on
[No workers' comp. insurance
required.] • 5. ES ' e are a c orp dation and its 10.0 -Electrical repairs or additions
3. 0 I am a homeowner doing all work officers have4xercised their .
.. 11.0 Plumbing repairs or additions
myself. (No workers' comp. right Of exemption per MGL 12.0 Roof repair' s . •
insurance required.) t '
employees. [No workers' . 152, *1(4), and we have no •
13.0 Other
' • comp. insurance reqUire.d.) • -
,
*Any applicant that cher-ks box #1 must also fill out the section below sltowin' g their vioricers' compensation policy information • - .
t Homeowneri who submit thii affidaVit indicating they are doing all work and then hire outside contractoz 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 whetheror not those entities have
employees. If the sub-contractors have employees, they must provide their workers comp policy number.
1 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 Se]f-ins. Lic. #: Expiration Date: - -
. .
kb Site Address: City/State/Zip: -
Attach a copy of the workers' • compensation policy declaration page"(showing the policy number andeiration date).
Failure to secure coverage_ as required. Under Sectidni`25A 'ofMGL c. 152 can lead to the iiiiPositirai ofaiiminal Penalties of a
fine up to S1,500.00 and/or one-year imprisonment, as 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 _.
liffeiiiiitiOns the" DIA his coverage veegi . ... . -- — . _ , _
I do hereby__cerd# under the pains and penaldes of perjury that the information providetabove_iitnte:iindearrect.____
. .
Sienatnre: ' Date: . . s
. , . .
Phone #: , . _
. - Officittl use only. Do not write in this area, tO be completed by city or town
Permit/License # _
City or Town:
Issuing Authority (circle one):
. ....... . •
•
.1. Board of Health 2. Budding Department 3. City/Town Clerk 4. Electrical,Inspector 5. Plumbing Inspector
1
1
6. Other ,
Contact Person:
Phone #: c-
CONSTRUCTION SERVICES
• d Construction Supervisor: /� Not Applicable ❑
anse Holder : r e---
G 0//1 a G f fJ r/f �i Z
AM License Number
Expiration Date
Telephone
�: 9'^ 4,'€#� kF' ,y ,� 7.,z � s�st d 5 : �� ; 8
i . dfn v nets +i jWafarz ;: ,, .., .y kt r r _ Not Applicable ❑
fi ; ix. f r1. l - L / e /9//11
f Name Registration Number
APO
L ye 7 f �, j Expiration Date
Telephone
N 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c.' 152, § 25C(6»
;Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
:nial of the issuance of the buildin ermit.
Affidavit Attached Yes No ❑
x Y
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 1083.5.1.
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
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check alt applicable)
New House ❑ Addition [❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding [a] Other [r
Brief Description of Proposed & //
Work:: h • ✓' �r .rk�t%L G��=t ,�' 6 +r>G�Z
Alteration of existing bedroom Yes t./ No Adding new bedroom Yes '''''' No
Attached Narrative Renovating unfinished basement Yes L/ No
Plans Attached Roll - Sheet
a b t diitf d o l e t s gig- f ' ttt �.'f i r rr .. ���
a` ��I�. I�B�i4����.' �C�d��������E��' 3���Ct :'�Q�1'p�i��'".k�11�'till>Iti�:
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 AUTHOR. IZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, / I rt ) A, o i j s , as Owner of the subject
property
hereby authorize 12A1/1 ✓r C 1.1 (o I r` .e..
to act on m all matters lative to work authorized by this building permit application.
� ///23 /Za /t5
Si of Owner Date
t c.!/' /O e (1 O , as Owne uthorize
Age hereby declare that the statements and information on the foregoing application are true and accurate, to the best o y nowiedge
dndbelief.
Signed under the pains and penalties of
Print Name
./" 7- I'ie
Signature of Owner /Agent Date
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Section 4. ZONING All Information Must Be Complete\l. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
(( Building Department
Lot Size i I
Frontage a 1
Setbacks Front 1 1
Side L: R: i L:1 I R:I _,
Rear
Building Height °°"
Bldg. Square Footage [] [ 1 % 1 = J
Open Space Footage t 1 % i I
(Lot area minus bldg & paved t ..E y S _ ?
parking)
# of Parking Spaces t '
Fill: j
i 1 .
(volume & Location) l € € -
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 O YES Q
IF YES: enter Book $ Page? ? and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q 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 0
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
IF YES, describe size, type and location:
E. WiII the construction activity disturb (clearing, gradin., excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO 0
IF YES, then a Northampton Storm Water Manageme t P -rmit from the DPW is required.
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City of Northampton - e ' z ,„ Buitdinggepartment - a `. = .. i
2 In ��ceot �. � �
. ffi� i y � ze "�
Room 100 __ ____ . E� ;
Northamp� , M 01
phone 413 5167 -1 F x 1 7 -1272 � 4 i"'
APPLICATION TO CONSTRUCT, ALTER, REPAIR, REN VATE (OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
K ,° --4 fruit,,,.L Map Lot Unit
`_/ Zone, Overlay District
EIm St District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print Current Mailing Addre
X — fPy i o7L
�— Telephone
Signature
2.2 Authorized Agent:
Na nnt) Current Mailing k4
Gf /T z i 7f
Signature Telephone
SECTION 3 - : ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
(a) Building Permit Fee
1. Building 7. 6.°
2. Electrical ,..r t' (b) Construction from (6) of
3. Plumbing Z �� Building Permit Fee
4. Mechanical (HVAC) A -ia
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 42 , add Check Nu mber / I
This Section For Official Use Only
Building Per Date
mit Number: Issued:
Signature' ` ���® � `�
Building Commissioner/lnspector of Buildings Date
A
.:" so 4. Ad BP- 2011 -0489
GIS #: COMMONWEALTH OF MASSACHUSETTS
a= .` 21 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0489
Project # JS- 2011- 000797
Est. Cost: $11000.00
Fee: $66.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID CHICOINE 061582
Lot Size(sq. ft.): 3789.72 Owner: JACOBS TIMOTHY J
Zoning: URC(100)/ Applicant: DAVID CH I CO I N E
AT: 5 EDWARDS SQ
Applicant Address: Phone: Insurance:
16 EDGE HILL PLACE (413) 246 -7536
AM H E RSTMA01002 ISSUED ON :11/23/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL BATH /LAUNDRY ROOM
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 11/23/2010 0:00:00 $66.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner