11C-030 (2) , •
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the riaht 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 boles (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 , Ia.. AL D. understand the above.
(: ome owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building. permit
issued to me.
Date 7U r
Address of work
location 5
-114
The Conzmanweaith of Massachusetts
Department of Industrial Accidents
—� O ffice of investigations
t�Y `
- 600 U asdzinatan Street eet
Boston, MA 02111
w'Y+'. mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
AD Dilcant Information Please Print Legibly
Name (Business!Orsanization Individuaii:
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
4. I am a general contractor and I
i. ❑ I am a employer with � 6. � New consuuction
employees (full and/or part - time).* have hired the sub contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling,
ship and have no employees These sub - contractors have S. ❑ Demolition
working for me in any capacity. employees and have workers' , ..
P 9. ❑ Bui�r7ing addition
[No workers' comp. insurance comp. insurance.*
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
'rte J
officers have exercised their 11.0 Plumbing re�a rs or additions
3` I am a homeowner doing all work r
myself. [No workers' comp. right of exe�u� tion per MGL 1 Roof repairs
insurance required.] ' c. 152, § 1(4), and we have no
employees. No workers' 13.❑ Other
i comp. insurance required.]
Any applicant that checks box =l must also :ill out the section below showing their workers' compensation policy ir_forrration.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:l-Conn that check this box must attached an additional sheet showing the narr of the sub - contractors and state whether or not those entities have
enroloyees. If the sub- cont: have e•no1oye =, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance C Name: —
Policy # or Self -ins. Lic. ;r: Expiration Date:
Job Sire Address: • City /State /Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DL"k for insurance coverage verification.
I do :ereby ceerrtifyunder the pains and penalties of perjury that the information provided above is true and correct.
i` nature: �Cf a Date: .. , - 7 - 0/t-' 42 -
Phone _:
0ffcial use only. Do not wrire in this area, to be completed by city or town officiaL 1
City or Town: Permit/License # I
Issuing Authority (circle one):
2, i Clerk 4. Electrical Ins ector 5. Plumbing Inspector i
3. Beard of Health _Build a n_ Department 3. City o�vn Cle: h Electrical p
I 6. Other
1
i Contact Person: Phone
SECTION 2 - CONSTRUCTION SERVICES 1
E.1 Licensed Construction Supervisor: 1 Not Applicable ❑
Name of License Helder
License Number
dress - Expiration Date
Signature Telephone
Registered Home Imnrovernent:Contractor Not Applicable ❑
:omoanv Name Registration Number
.ddress Expiration Date
Telephone
ECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. C. t52,. §.25C(& ))
'crkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit.
aned Affidavit Attached Yes ❑ No ❑
11.. 3om, Qw> et° Egemtitto
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 ofland 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 -vear 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 Iiable 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 r •
f
i SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House n Addition 7 Replacement Windows I Alteration(s) 7 I Roofing i
Or Doors EJ
�-
Accessory Bldg. ! ! Demolition 7 New Signs [DJ Decks [ Siding [ Other [pi
Brief Description of Proposed / C�
Work: — / � y � �/ (9...q, � ttG� -�- QQ
Alteration of existine bedroom Yes a No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes j ik No
Plans Attached Roll - Sheet
6a. if New hous and or additio to existing fiousin co '
et e ow
the falli
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 cf heating? Fireplaces or Woodstoves Number cf each
c. Energy Conservation Compliance. Masscheck Energy Compliance foram 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 Tt}SE COMPLETED WHEI.1
OWNERS AGENT OR CONTRACTOR APPLIES FOR BCIILDING=PERMIT
I , as Owner of the subject
property
hereby authorize .
to act cn my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I � d r
as Owner /Authorized
Agent , ereby declare that the StciemEniS and information on the foregoing apGIICaIICn are tree and accurate, to the test of my kr.CWiedge
and belief.
Signed under the pains and penalties of penury.
Print dame
Scr,atur= of Owner /,cent
I
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
1 Existing Proposed Required by Zoning
_ I This column to be filled in by
Building Department
Lot Size _.__..• _......_ __ - -_ ..11_,1 ,._._ - -._ I ...__ . ..__ .. ... _ _ _ __r
Frontage ___ __ _.. _.___.__ __ _,_..
Setbacks Front
Side L: R L ._... R
Rear _.: —
Building Height _ y I °mm_ mm 111
Bldg. Square Footage _ . _ % _._•-__' _.__._._
Open Space Footage _ _ __ % --- .
_.
(Lot area minus bldg & paved Tr _..w......V.
noticing
# of Parking Spaces �� -~
Fill:
(volume Sc. Location) -•– •- -•- ----•.. - — 11117 1711,1 _
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO y.� DONT KNOW 0 . YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW 0 YES 0
IF YES: enter Book Page;___ ._ and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued: _
C. Do any signs exist on the property? YES NO V,
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
IF YES, describe size, type and location:
E. WII the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a coi,niron plan
that will disturb over 1 acre? YES 0 NO 1141
IF YES, then a Northampton Storm Water ManagemerifPeimit from the DPW is required.
Department use only
�- City of Northampton Status of Permit.
\ 9 p y
il "� BUilCin De artment Cu rb CutlDrivewa Permit
`� \, \ \ 212 Main Sleet SewedSep icAvai1abWty
-. Room 100 Water/Well Availability
In . Nerh mpton, M r . 01060 Two Sets of Structural Plans
^,\ 5 ` p e 413 -587 1240 Fax 413 -587 -1272 Plot/Site Plans
` C , G���RS Other Specify
c-
\, "APPLICATIOJ4 T>13 @!� UCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 C SfTE WFORMATION l
1.1 Pro r y Ad dress: This section to be completed by office
� � S I.--
Map Lot Unit
Zone Overlay District
--r��S /YI l 3
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: /�
� C is, 7 /g t- /4I 5 5 5>Z 10- S r
Na e (Print) Current Mailing Address: --
2J - Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current iiing Address
Nra
Signature Telephone
SECTION 3 - !ESTIMATED CONSTRUCTION COSTS .
I
Item Estimated Cost (Dollars) to be Official Use Only'
1 completed by permit aoolicant I
1. Building 1 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee .
4. Mechanical (HVAC)
5. Fire Protection
6. Tctal= (1 +2 +3 +4 + ( Check Number
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
Building Commissioner /Inspect5T r budaings
Date
1
::> TE ? BP- 2008 -1091
GIS #: COMMONWEALTH OF MASSACHUSETTS
Ale - p3p 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- 2008 -1091
Project # JS- 2008 - 001613
Est. Cost: $1000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 8102.16 Owner: BLAIS ROBERT E
Zoning: URA Applicant: BLAIS ROBERT E
AT: 5 STOWELL ST
Applicant Address: Phone: Insurance:
(413) 585 -8195 0
LEEDSMA01053 ISSUED ON:6/5/2008 0:00:00
TO PERFORM THE FOLLOWING WORK: NEW GARAGE ROF
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: Waugh: 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 6/5/2008 0:00:00 $25.00144582
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo