31B-020 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 hall 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, ° 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 backfilp
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
iermits 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 me.
Date .
Address of work
location
' 7
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. The Commonwealth ofMassachusetts
Department of Industrial ACcidents
l i■ ..-r.•:: —, •= 0
Office of InivstigationS
600 Washington Street
Boston, MA 02111
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www.mass cvv/dia
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-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information • Please Print Legibly'
- •
Name (Businesi/Organization/Individual): 51Cf ( .
. .
: -
Address: e ,.
• . __4 5
•
e-
City/State/Zip:4,j1/(P.,„ / /32,- zv 2 2 Phone.#: 4/3 i2 2- 2/ .?- X
Are you an employer? Check the appropriatehoz: • • •Type of project (required): /
• 1,4 i am a employer with Z-- 4•. 0 I am a general contractor and I
6. 0
employees (fall and/or part-time). New construct - • '
have hired the sub-contractors
listed on the:attached sheet 7. it BemOdeling
2.0 I ani a sole proprietor or partner-
These sub-contractors have -8. 0 Demolition - . • •
• ship' and have no employees
.
world/1g f a any paijacity. _e:P4PYPc.4-_?110.4....Ye Norice.:rs' 9 ifilitii a
[No workers' comp. insurance •
required.]
5. 0 We are a corpora.tion and its 10.0 repairs or additions
___,
3. n I am a homeowner deing all work officers haVeC ll
tereised their .
.t 11. PIttinbing repairs or additions .
myself [No workers' comp. • neat of exemption per MGL
120 Roof repairs .. . •
insurance required.] t • • ,c 152, §1(4), and we have no • ._ . •
employees: [No workers' 13.11 Other
- . •
' . comp msmanoe requzredj
Any applicant -that checks box #1 must also fill out the section below showing theirivockers compensation policy infounatfint;
t Homeowneri yvho submit this afradaVitincrinating they are doing all work and then hire outside contractors must submiia new affidavit indicating such.
1 -contractors that check this box must attached an additional sheet showing the name of the subL-contractots and ' state' whether or notthose-entides have
employees. If the sub-contraitorshaie employees, they must provide their wcirkets' comp policy number.
lam an employer that isproviding workers'e.ompenscrtion insurance fortify einplOyees. Below s the policyaruljobsite
information.
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Insurance Company Name: 7 C.. 'a..--v - 1 2 . 4A. , - $ , e'''',e . . -.. - : ' : •
i i — i Z
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Policy # or Self-MS. Lic. #: 5-1---A...2 c 2 1 .- 1 1 1- / _r, Expiration Date: - "1" /Y.'. `../ / 4---
,r
Job Site Address: /e ../7 Z e•- -/-) .5.-/ • • - CityiStatelZip:' /2i,V,V4..- : (9./
Attach a copy of the workers' compensation policy declaration page the policy nuinber and expiration date).
. . , . _. ....... __.
Failure to secure coverage iS reqUited Under Seetibli'25KofMGLc: 152 can lead iti the imposition of'Ciiininaliaenahies of a
fine up to $1,500.00 and/or one-year insprisonme4 as well as civil penalties in the form of a STOP WOP4ColupgR and a &_e
' of up to $250 00 a day against the violator Be advised that a copy Of this statement may be forwarded to the Oiffee of
HieslikatiOnSiiftliE r
DIK ' _ • • . ' - -- - - : --- . :. -7 -.. ' , -, 7- : ,
herebysertifirunder , ' p ‘ i . : and penalties ofperjury tkaithe ithovei .....
• / ,
.
Si.. -tare: -4111 ,/` • • - • -.. TH' ' • Da.th: 2 7 Z' ----// - •
• ,
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Phone ii: 32 2— 2/-1. . - - _ • - • .
- - - --- ,-.
-Official use only. Do not write tri this area, to be completed by chy or toWnbfficiaL
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City or Town Permit/License #
:
Issuing Authority (circle one):
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:1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
— Not Applicable ❑
v
Name of License Holder : ) /2 A� � �� �'��SJ� 0 , 25a/
License Number
Address Expiration Date
X27 7/27
Signature ♦ t 9 Telephone
ttaRt aisteie Haiidewtmgrau meWt oi�ac t+e>r ...,. - A ig r ViiiiNkAilikiltil Not Applicable ❑
k4/11 (;4 /IX
Comp nvv Na e Registration Number
Address ✓ Expiration Date
£ y �'G -fA u� As Telephone f1 7J
r')/oz?
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 i li No ❑
f �K metg en tb � n
The current exemption for "homeowners" was extended to include Owner occupied Dwellines 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) it Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [D] Other [lJ
Brief Description of Proposed
Work: ('‘44 S��J� �iv,� /"<-/(1-
.- /(J ,/ ,f - ! 'adA T 5 t' e d2 117j &-
Alteration of existing bedroom Yes No Adding new bedroom Yes k No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa... r;t�rs a►arilto:irt ;+p►lfc>ltic .
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
1, x
/&/A1/4/_1 /2 /C -e as Owner ofthe subject
property �
hereby authorize d r�4/ (1/
to act on behalf, in all m ersative to work authorized y this building permit application.
X
Signatu f Owner Date
S 4 1 /f/YY
£ 1 4' 2 , as Owner /
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and bblief.
Signed under the pains and penalties of perjury.
>>
Print Name
Signature of Owner /rent `` Date LLL
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomple Information
Existing Proposed Required by oning e ;,,
This column t be filed in by
Building Dep £tnienj„
Lot Size 1,_, ........, _ _ __.__ �. [ _ _ w __ —__ , 1
Frontage =- -- .-
Setbacks Front 1 1
Side L :? -J R . L:1 i R:! .: , , 7 I
L i
Rear ___
Building Height i ? 1
Bldg. Square Footage I — I% F = 1
i a
Open Space Footage % l
( area minus bldg & paved I . s L_.....1 1
parking)
# of Parking Spaces 1
Fill:
(volume & Location) 1! F
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES 0
i
IF YES, date issued:I i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book 1 Page 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 0 Obtained
, Date Issued
C. Do any signs exist on the property? YES 0 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 0 NO 0
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 0 NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
l } ��� ip �
• + f +: � '� :11 14. ° ,,,--. u � ' w ' ftt
City of Northampton ¥ s ® �r -����
i Building Department ' > , s -
` 212 Main Street m
Room 100 4, ,� I:
• �iampton, MA 0411036-5087- , � ''
\ , tote* "'�� 13 -587 -1240 F ax 1272
�` ��
` APPLICATION 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:
/� tDv, Ar 5' Map Lot - Unit ` -
�e> '' y�l c �Gc )/06.o ;Zon Overlay Distric
Etn1 St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Gs-t- �` + Telephone
Signe
2.2 Authorized Agent:
c :,,/e7,04-_4.4_ .,._ '';'Cit-IP
Name (Prin Current Mailing Address:
T
eGJ
T27-2/ " p4/414/'
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item
completed by Pe
Estimated Cost ) to be Official Use Only
rmit (Dollars applicant
1. Building ., (a) Building Permit Fee
e).0‘,. 4' "
2. Electrical (b) Estimated Cost
Construction from Total (6) of
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection _
(1 ) S`v'P'y, v� Check Number 3
6. Total = 1 +2 +3 +4 +5 a
This Se For Offici U se Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspe of Buildings Date
File # BP- 2012 -0019
APPLICANT /CONTACT PERSON STEPHEN CAMP
ADDRESS/PHONE 46 EAST ST EASTHAMPTON (413) 527 -7124 Q
PROPERTY LOCATION 10 ALDRICH ST
MAP 31B PARCEL 020 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid C � /� a
�J / j
Tvpeof Construction: RENOVATE BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 082531
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOGIATION PRESENTED:
( t/ / 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
Demolition Delay
C l 7 fi 1
Signature of Building Official 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.
10 ALDRICH ST BP- 2012 -0019
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 020 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0019
Project # JS- 2012- 000033
Est. Cost: $5000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEPHEN CAMP 082531
Lot Size(sq. ft.): 5662.80 Owner: RICE RACHEL
Zoning: URC(100)/ Applicant: STEPHEN CAMP
AT: 10 ALDRICH ST
Applicant Address: Phone: Insurance:
46 EAST ST (413) 527 -7124 0 WC
EASTHAMPTONMA01027 ISSUED ON: 7/13/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: RENOVATE BATHROOM
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 7/13/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
1