31B-023 (2) 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
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
. .
• ,
. The Commonwealth opfassachusetts
..■,..., .........11 Department of Industrial Accidents
p l , -........"•=r—=. m
Office of Investigations
600 Washington Street
•=1:1:r A-, =. ', Boston, M_A 02111
,..... --...---:-„,
www.mass.gov/dia .
....
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information - Please Print Ligiblv
Name (Business/Organization/Individual): 8 9 ) 6 1 Ai 6 j eio, '... a --. - A 7 e- ,
io
. ' Address: g , d.„..., /
City/State/Zip: Ahe.;d ig i3 - 4 / 4 ' Phone.#: 6-. i?; -- `Y/6 7
Are you an employer? Check the appropriatebox: • Type of project (required): /
1. FE I am a employer with 2— 4. D lam a general contractor and I ...
6. 0 New construction
have hired the sub-contractors
employees (full and/or part-time).*
listed on the attached sheet 7. 0 Remodeling
2. 0 I am a sole proprietor or partner-
• • ship axuibave no i).loyees These sub-contractors have. .8. 0 Demolition
working for me in any capacity. enloyees and have worke rs ..,. ___ __ ,__. -
9 - 0 Building addition
[o workers' comp. insurance _ conv.insrmnr # '
10.0 Electrical repairs or additions
recluire ' 5. 0 We are a corporation and its
3. U 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 repairs . •
insurance required.) t • c. 152, §1(4), and we have no
employees. [No workers' 13.0 Othei
. ' comp insurance reqUir-ecti
•Any applicant shat checks box #1 trazst also Mt out the section below showing their worioers' compensation policy information. ': •
t Homeowneri who submit this affidaVit inclicating they are doing all work and then hire outside contractors 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 wi3etiser or not those entities have
employees. If the sub-contraitorshave employees, they must provide their workers' comp. policy tum7ber. • .
-
I am an employer that is providing workers' co mpensation insurance for my einploye.es. Below is the policy and job site
information. ,- •
1/ In
Insurance Company Name: - %Jr; , ''' i - I ---...„ t -''' ' •
I
• • • .9 ,..., , , 1
Policy # or Self-ins. Lic. #: LOC-c -- 8/6 ' 3: 1 ' 71 - 0 /7' Expiration Date: - 0 i i
ii / C I
Job Site Address: ii A - ..,- ( " L 4-- - • del (.41 7 To
i 7
City/State/'Zip: , - _-
Attach a copy of the workers' compensation policy declaration page (showing the policy nuniber and expiration date).
......
Failure to secure cOverake . as required raider Section 25A ofMGL c 152 can lead to the imposition of din:IMO 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 wop,x_oRDER and a fine
of up to $25000 a day against tile violator. Be advised 'diet a copy of this statement may be forwarded to the Office of ,......
InVeitizations &the DIA for insurance 66viriiei
_ I do herebycertifr under the painsand penalties olperjray that the information providerraboveisinze_araiorrpet _
--y - . - - 15a - cfCci r ...- 4.0/0.. ,
Phone 0: s.CF6-: - "/". 7 ' . - - • -
Official use orzly. Do not write in this area, to be completed by city or town officiaL
. .
• City or Town: • Permit/License #
Issuing Authority (circle one):
.1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector
6. Other . 6- • •
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : L= am r L� 1 , ' ,
yy,� License Number
7e/ , d / , 1 ,2, /CMG 0J.6 s
Address Expiration Date
Signature Telephone
0/- --47.1 '/V
` 1 5 ` Not Applicable ❑
;S ii~ eslisitee d. ��ictim") r�sirovetilea`tairtraara"�'.�.�i:`� �Q,�;���,.�. PP
S WIZ/6 5,0
Company Name Registration Num)er
Address // Expiration Date
4 k ^ /k S � % vi Telephone p - 7 S' i 6
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 build' `g permit.
Signed Affidavit Attached Yes No ❑
Jaw, '' 8 er"Ex li
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) ❑ Ro fing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding ] Other [0]
Brief Description of Proposed �n 5 r/4 /, 1 `>
Work: � (6 % t
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
.6 it ii a a ridit d i$t Yq enli . a ifit f tti taltai aii
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
U ill 5 / 2 , as Owner of the subject
property G
her y authorize C- 1 ij L /
to behalf, in all matters re ive to work authorized by thi building permit application.
Signs re of Owner Date
z — '�' �� °' �� �?' , as Owmnar /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.
Print Na
/S ' .r i 0 / 0
Signature of6 /Agent Date
, 1.
Section 4. ZONING All Information Must Be Completed. 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
Frontage
I
Setbacks Front J - 1
Side L: R: ' L:1 ' R: ° 1 1
I 9
Rear
Building Height { I
Bldg. Square Footage i I =% 1 1 =1 1
Open Space Footage ; %
(Lot area minus bldg & paved € , , 3 € .....-__
parking)
# of Parking Spaces ,_.
Fill: i , _... n.e
(volume & Location) - i 3
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 1 i Pager 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 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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
,
t ,
City of Northampton Y f � �t`�
Building Department ffi „* F .
212 Main Street 4 : - ?-
Room 100 r , V
r . Ep� �
b � d,
APR or d' Northampton, MA 01060 � 13- 587 -1240 Fax 413- 587 -1272 . x Y z
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.1 Property Address: J
LD This section to be completed by office
h A ��
/ g /(11 Map ' Lot � � =Unit
(”, r�'j Zane Overlay Distract
Elm St. Dlstrlct CB. District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
A "SdA /4/>,- _ 19 4/e,..-..,( h. s r
Name (Print) Current aili ess:
! r ddr , moo ) n4,4_, a ,
1 it , +< Tele. ..,e, /3 --
Signature / t ��
2.2 Authorized Anent: (
7 4: (2 Name (Print) ( Current Mailing Addresg: i f—' ‘I''''''-7 itic,,lkAre- .—'" / / 4/11 ' /1-
Signature Telephone 6-6 -
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
_ com Ieted by permit applicant
1. Building 70 (a) Building Permit Fee
2. Electrical „.---- (b) Estimated Total Cost of
Construction from (6)
3. Plumbing r Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5) il C _ Check Number I f /J _ '
This Section For Official Use Only Iv
Date
Building Permit Number. Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
Mi. , .,. HST BP- 2010 -0947
GIS #: COMMONWEALTH OF MASSACHUSETTS
Witifiern0 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- 2010 -0947
Project # JS- 2010- 001406
Est. Cost: $7700.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R SIDING 026846
Lot Size(sq. ft.): 3136.32 Owner: SHEA MICHAEL H JR& JOANNE SHEA
Zoning: URC(100)/ Applicant: B & R SIDING
AT: 19 ALDRICH ST
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586 -4167 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON :4/28/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK INSTALL VINYL SIDING
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 4/28/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo