25A-027 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, 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
•ermits 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 wner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date - 1 - 1 • 2.D
Address of work
location MC.S' /4 A-LL
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. The Commonwealth of Massachuse
-.4.----- . Department of Industried ACcidents
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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/PI
Applicant Information . Please Print liegAilv : :1
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Name (Businesi/Orgoniiation/IndiviAnn1):
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• !
• - Address: ,.. • . • ,. -
City/State/Zip: . - . Phone.#: • -
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Are you an employer? Check the appropriate'box: . • . •Type of project (reqttired):. . ,
1.0 I am a cmployer with 4.. 0 I am a general contractor and I
6. 0 New construction
employees (full and/or part-tirae). have hired the sub-contractors
2.0 I am a Sole pi-oprietor orparMer- listed on the attached sheet. 7• 0 Remodeling .
. ship ond have no eoloyees These sub-contractors have •8. 0 Dein Olidon - .
ive workers
miloyee s-Ondla' : . - - - - ,- -.- •
working for rae in any capacity a
. - - ---------- -• • 9: = 0 liktildiftg'asIdidii
_ .i requirei] •• .
5. 0 We are a coloration and its 1 Electrical repairs' or additions
•
3 I am a homeowner doing all work officers haVe- xeraised their 11.0 Pluinbing repairs or additiOns .
myself [No workers' comp. - right of exemption per MGL 1-1 • .
12.0 Roof repairs - . •
i nsurance r t • . . . 152, §1(4), and we have no -
employees: [No workers' . 13 Other r .
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• . - . comp insurance reqUirecL). - ' . • - • • • : • .
*Any applicant-that che:cks box ftl:must also fill out the section below showing their iforkers'-compensation policy in:formai:at.
t Homeownern who submit this affidairitincfieating they are doing all work and then hire outside contraiorn must submila IICSV affidavit indicating such.
:contractors that check this box must attached an additional sheet showing the naie of the subcontractors and se wietheror notthose•entities have . . •
employees. If the sub-contraitorsliie employees, they mustprovide their wars 7 comp poky number. , : - , *. . _••• : I. - • .
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- . I am an employer that is providing workers' compensation insurance for my employees Below Ls the policyandjob site
information. : • .
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Insurance Company Name: • . • • . .
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Policy # of Self-ini. Lic. #: . . Expiration Date: - - • : • •
• • . . .
Job Site Address: • - • • • City/Sta.triZip:' - - . -. • - - .-
• Attach a copy of the workers' compensation policy declaration page (showing the policy number an4 date).
Failure to secure Coverage . as retiiiirediirileir Seeti lead to the hi:Oa:Uzi of niinal iienalties of a
fine up to 51,500.00 and/or one-year iinprisonmenc as well as civil penalties in the form of a STOP wogic-o.pDart and a ac
of up to 5250.00 a *against the violator Be advised that a copy:Of this statement may be forwarded theOiriCelof,... _.., .
ffiV` e _ 7 - . • - ..._. . , -,. _II :;:,_„: :::_ _...„.' _I ,,:,._ .:,....,.
, Lab hereby.Certifil. under the pains . penalties ofperjury that the informatiOnprovidertabovelsidte_andCorroet
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Phone ii: • . • _ . . ‘. • .
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Official Use only Do not write in this' area, to be completed by city ii town OffiCiaL
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• City or Town: . Permitalcense # „...,,
Issuing Authority (circle one):
.1. BOard of Health 1. 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 ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9c,:Registere%.Hairtie Improvement`Contractor•�,xr ��� � � , -�� � �"` .. s Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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 ❑
He >ciil fl el eM leg
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 ac ts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own a parce o 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 d Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signatur
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [0]
Work: efDescription of Proposed
n r 0 tie n O Al e 1- iC R
Alteration of existing bedroom /� Yes V No < Adding new bedroom Yes ( No
Attached Narrative Renovating unfinished basement Yes (/ No
Plans Attached Roll - Sheet
6 . i#Wirl stla lge Ind" aC.aciriition to kfiii iif io slnq iimpt tithe €6Ik viinq:
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
I Ye- r . l\ ny � \A a W , as Owner of the subject
property 'Q
hereby authorize ►Jar fedora,
to act on y behalf, in all matters' relative to work authorized by this building permit application.
�( --A--"... 'J" ''1-N-- • 7. 201 i
Signature Owner Date
I, \e r i r r\Ae Still , 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.
t✓� N►\rne SV‘duJ
Print Nam
Signature of ner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information ~ 'e
Existing Proposed Required by Zoni "f
This column to be fill in by i i
Building Department '
Lot Size 1 I L___ (,_ .� F# __.
Frontage I I 1
Setbacks Front I i E= I I
Side L: i _.__ I R: _n_ _ I L:I R:1 ! 1
Rear 1 i 1 I d '
Building Height 1 1 r 1 t r 1
Bldg. Square Footage 1 F—I % 1 1 1
I
Open Space Footage
(Lot area minus bldg & paved „„�, _I i a l
parking)
# of Parking Spaces 1 1 r--
Fill: i
(volume & Location) L ' .
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW ® YES 0
I
IF YES, date issued:, I
3
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book l Page [ and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued
C. Do any signs exist on the property? YES Q NO st
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 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 Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
t. �„l -' i. a 6 $ ® -
EIVED City of Northampton A � $, ` ,, � , ,
Building Department V x" e �"� , �,
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gen
r (� Room 100 212 Main Street _ �J
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.E� � y y � , ,� A::1
Northampton, MA 01060 ��
a';�� - _ 413- 587 -1240 Fax 413- 587 -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: Pk
%
�Kst4 4 LL E / Map Lot Uni
JY6R- —� 4 ✓vi 6 Zone Overlay District
Efrr► St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Ker ! s t 5 2 m „h„1I S.\-. N0r-1- 1 MA
Name (Pri ) _ CJ . �--' Current Mailing Address:
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 / , 0 D 0 (a) Building Permit Fee
2. Electrical (p (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) ( 0 000 Check Number / 3S
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
23 MARSHALL ST BP- 2011 -0807
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A - 027 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP-2011-0807
Project # JS- 2011- 001327
Est. Cost: $6000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 7840.80 Owner: SHAW KERIANNE
Zoning: URB(100)/ Applicant: SHAW KERIANNE
AT: 23 MARSHALL ST
Applicant Address: Phone: Insurance:
23 MARSHALL ST
N O RTHAM PTO N MA01060 ISSUED ON: 4/7/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:SHINGLE ROOF OVER 1 LAYER
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 4/7/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner