31B-138 (2) J
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 occunancv
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
jerniits 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 me.
Date
Address of work
location
I rr
1, • ,, ,
. c\ The Commonwealth opfassachusetts
Department of Inclustrird Aecidents . ,.. .
P k ."■..' 1. ra A 0
P. 9' r:-":71C.: El' Office of Ini
600 Washington Street
: ,:iLif Boston, .111,4 02111 . •
?.... -= 47
gov/duz
oia • - ..
-25
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
....
Applicant Information - Please Print Legiblv
..e .
Name (Businesi/Organiiation/Indivianal): 1,g x i v .e , ./
• Address: /7 2_ ,te," 5,,,,,,,7 5,_ ,- • -
,
City/State/Zip: f3.--, Phoneg: 32 7— 6.--4 CP ar „
. - • 'I'
Are you an employer? Check the appropriatebox: ' -Type of project (required): /
•
1.0 I am a employer with .. 4.. D I am a general contractor and I
6. 0 New construction
have hired the sub-contractors
employees (fall and/or part-time).*
2.0 I ani a sole proprietor or parer-
listed on the:attached sheet: 7. 0 Remodeling
ship d ave n loyees
- .
These sub-contractors have. -8. 0 Demolition
;a ho emp
emiloyces-inciliaye workers' -. -- •
working for me m any capaeily. - 9:1=3 cu
t
: -
[No warkere comp-. insurance ' mr-C- - - -
required.] i, -!--------;-- - - • . .
5 . e are a coxpo an d it 10.0 Electrical repairs or adcations
.- .- .
' 3. 0 I am a homeowner doing all work officers hai their . 11.0 Plumbing repairs or additions .
myself [No workers' comp. • right of exemption per MGL r--1 . .
12.0 Roof repairs . •
insurance required.] t ' . : c. 152, § 1(4), and we have no •
eniployee. [No wor 13.0 Other r •
,
• • .
1 - -
*Any applicant-that checks box #1 , must also fill out the section below.showing tizirivorkere campeisation policy informatiOn.
t Homeowneri volto submit this afftdaVitincficating they are doing all work and then bir' e outside contraCtors must submit new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub ;contractors and state whether crrnottivaseentities have
employees. 'If the sub-contractors haie employees, they must provide their wor]cers comp policy number.
I ang an employer that is providing workers' compensation insurance for my einpliwes. Below is the policy ruzd job:site
information. . . • .
.
' . - • -
Insurance Company Name: • •
. • . , . .
Policy # or Self-Ms. Lic. #: - Expiration Date: - . • ,
Job Site Address: . : - - ' '. City/State/Zip:'
Attach a copy of the workers' compensation policy declaration pige the policy numbe and expiration date).
_
. . . , . .
Failure to secure coverage as reqiiiteirtinTdei.Settiat 2 OfMGL "6: 1526 lead to the irbposition ofaiiiting. - Penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil Penalties in the forni of a STOP WORK-ORDER and a fine
of up to $250 00 a daY against the violator Be a:dvisecl that a copyof this statement may be forwarcled.M the °ace:of
Evesiiiiiloiii the forliiiiranceeiiiiiiie veacition. _ . . - ' _.._ _ .,...... - : - . - ...,...: .:,.,... -....,,......,......„.„.: ... „,_ ..„ ,._,
_ Ida Itereh_vee ' n _ p ' and aides ofpajtay mat the infOrmationprOvidi.daveliin i;ct.' ...
. . ‘.. • • • ' - - - - - - ' - - ' ---7-' . (' --7- , .
Signature: Li Date: e..7 .
. . •
---,,,- c,-
Phone -
#: ...- 7 - 7— c .4 7.--. tie 43. • • - - ' - • • . .
. - Official use only. Do not write m this area, to be completed by city or lownifjjleiof
. -
• ' . ' • .
City or Town: ”. Permit/License # '
__ .,..
Issuing Authority (circle one):
:1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspeetor 5. Plumbing Inspector
6. Other . . •
1 Contact Person: Phone #:
• -
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Ap
Name of License Holder : IC€ ;/ / ,i/ 4 19Al l L [ 1 tU y
License Number
/2 2- el , // .r( G. Gti // — z 9 -z/
Address Address Expiration Date
Signature Telephone
9. ",ReCtistered Hartle•fmtirbVemerit =Cant eibr . ..: MZ l; i 1. ,, , Not Applicable ❑
4y,� A , P , ` c / 9 „ e . t £e o%L;; f 11/ //1
Company Name Registration Number
Address Expiration Date
Telephone CZ7 -G2 6 E(
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 ❑
11 ... ome thtl er. a pti i.n
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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) J Roofing El
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [IL] Siding [0] Other [0]
Brief Description of Proposed, I__ O t� n � Q
Work: rye e So 'F
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa Cf [ nr #>Io tse and�r �dcli ri a x �t ct. birslnq; irnplete, the: t HOwwana:
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
� T.1
ditvi t�i0/6 , as Owner of the subject
property l '` r
hereby authorize
to act o my behalf, in all matters relative to work authorized by this building permit application.
1. .4A /L_f _�'. t
Date
I, / v )1./ Ai G 4a -- , 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.
RCA
Print ame
Signature of Owner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning i
y
This column to be filled in by 1
Building Department
.
Lot Size i u 4
i
Frontage 1 a . ~— ___. L. ...._ , . i
Setbacks Front i i 1 1
Side L E ~ . R i L:! .....___ R:L__ !
--
Rear 1 ' i
Building Heighty
Bldg. Square Footage l Erni % E 1 , r 1
Open Space Footage %
(Lot area minus bldg & paved _,
parking)
# of Parking Spaces
Fill: I 1
(volume & Location) --• ----- ---- m
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 $ , Page' . and /or Document ft;
m _. __
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q ,Date Issued
C. Do any signs exist on the property? YES i NO 0
IF YES, describe size, type and location:
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. 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 Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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t-4,,.-.-z-,,,, ,,,$;1„.„_,,,;,,, t ‘ i ...irtm, ai ki : ,4 0 „: 01 , - *4;13i; -,,,,,,,::: . , ,,,--
, , r City of Northampton aTu6,o -1 ; h
R ED ` .. _ Duildin Department
212 Main Street dil
1 I r. >h ` i i 1s ' ® u h
i �� I Roo 100
N rthampton, MA 01060
, p E�
QEPt OF BULD , , iloris 41 587 -1240 Fax 413- 587 -1272 1 f '
NORTHAMAPT0'i. )l. 0 J a j, % "` J t '
� 5"
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
g i� 4 p-- Map Lot Unit _
Zone Overlay District
Elm St Dist CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Nct vie ci M e 2Ag er (j� 9 . /Jo r4- r» ii)-J -dYm
Nant) Current Maili ress
�n �, /1 X02
Telephone
t4
ur
2.2 Authorized Agent:
l�— �1//yv /- e; ,c'G/ /2 2- /e ,,_- /� S
Name Print) Current Mailing Address:
527 - 6Z6
..//-`;
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building t 5 oel7) (a) Building Permit Fee
I v
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection ei 9 !/3
6. Total= (1 +2 +3 +4 +5) Check Number /Q
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature* �� / l - �/
t
Building Commissioner /Inspector of Buildings Date