25C-023 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
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
Date
Address of work
location
• 4 T
The Commonwealth of Massachusetts
=. Department of Industrial Accidents
W`iirli� Office of investigations •
= 600 Washington Street
=Y f B oston, MA 42III
www.mass gov /din .
•
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers
Applicant Information / Please Print Legibly
Name ( Business /Organization/Indivianal): V P k5/ c 6 iu 6 v ,_L A ) (.._ • - Address: ,e6 )3/z) ,40 " •
City /State/Zip: ,4 Q7) .4 7z)') "34'0. t()‘a Phone. #: J e4 - 9/C7
Are a an employer? Check the Type of P o) ect (required): box: e r' r /'
.
1. I am a employer with 4. 0 I am a general contractor and I 6. El New construction
employees (full and/or part-time).* have Hired the sub- contractors
2. .0 I am a sole proprietor or partner- listed onthe:attached sheet. 7. 0 Remodeling
ship and have no. employees These sub - contractors have S. ❑ Demolit;.on
working for me is any capacity employees andhave workers'
9: Building addition
[Nei workers' comp. insurance comp. mamrran�P # .. —._ .:.
required:] 5. 0 We are a corporation and its 10 ❑ Electrical repairs or additions
3.0 I am a homeowner doing all work officers havexercised their 11.0 PIutnbing 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 Other
• • comp. insurance required.]. -
`Any applicant-that checks box #l- must .also fill out the section below showing thcirworkers'.- compensation policy information.
t Homeowners w h o submit t h i s a $ i d a v i t .. i n d i r a t i n g t h e y are doing a l l w o r k a n d t h e n hire o u t s i d e 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 whether or notihoseentities have
employees. If the sub - contractors have employees, they must provide their workers' comp.pohcy number.
I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name / is ,=;-./2,
7/ M c r o ( �,S G
, rf Policy # or Self-ins. Lic. #: if.) C .j — .3 / J 3 r / )T / / / 0 ! 0 Expiration Date 0 J /3" as() /(7.)
�
Job Site Address: , — i�, � G, 1 /7 U C /S tate! '4 TO i .. it - Q / `� �
Attach a copy of the workers' compensation policy declaration page (showing the policy number and'expiration date).
Failure to• secure coverage as required 'Under . Sectthn 25A'of1GMGL c. 152 can lead to the imposiitiion 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 WORE _ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investreatlons of the DIA forinsuran ce' covers a vori ca tion. , _ . �: _,1
_ life hereby_ certify under the pamns.and penalties ofperjury :that the information provided bove.is_id:ue_andcorr ct
., _l -r � Date; ( , ` V !•
Signature 7 ✓ D / v c /
• Phone #: r __ 1 , - • •
Official use only. Do not write in this area, to be completed `
- O ff inpleted by cry or town official
City or Town: #
- Issuing Authority (circle one):
.'1. Board of Health 2. Building Department 3. City/Town Clerk . 4. Electrical Inspector 5. Plumbing Inspector
6.Other .
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Lr 1 it)." t L )2 A. /3-
D ) j 60 License Number
1 7 9) eizt,/ aeo,A0 adicire:74.4 n4.4_ C2;16
Address Expiration Date
Signature Telephone Oi r 7 (Pz
set 7
�j _ �,s:�s� ��, �t;,'�.,,.,�,, � Not Applicable ❑
�'' z�2@ 4" i5�1�1��I�F�111�Fn� 'OY@Tt� @t1�O `
Company Name Registration Number
;b ' J 6 5 . L & C- //90
Address � Expiration Date
g� t 0- iI IAf A 77 g J /67 04 %F ad e
0/
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 ❑
fUS bitiettnultrExemptiOn
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, von 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 D Addition ❑ Replacement Windows Alteration(s) E Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [IT/ Other [0]
Brief Description of Proposed /
Work: yji i /l U /l�j fi Ric 3 / 3 . i i
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
s `Ifiligiffabiiiir . .ici = kl5tiniaA s teSiii»ii fe lifile l` i :
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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN ,
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
,k
I, v Ci4 25 /' S� �*7 `V 1 , as Owner of the subject
property �-
hereby authorize L I J' 0 L. 13 'ZAii
to at on my beh i f in all matte rel tive to work authorized by this building permit application. -z
4 a Signature of Owner Date at ?` NI-13 rj ( °) /
I, 61 81vi N L i , as r /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.
i w . nl L rs 0,40/
Print N m
,...-1-,— J- ij, a,"4 a -.7 , ,) N c).0 11
Signature of ✓/Agent ? Date
r
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information . 'i
Existing Proposed Require by Piling y t
This col to bE filled y i � n � by j
'y
Building artment ? [t
' Lot Size I
1 I I 1- s
Frontage L 1 a 1 s .<, .....
Setbacks Front ET
Side L: i R:1 _.1 L: _ R: '
Rear
i
Building Height I I ."""""_, i
1 i
Bldg. Square Footage ( % ( t s
I i
Open Space Footage
(Lot area minus bldg &paved i _ , e
parking)
# of Parking Spaces
Fill:
(volume & Location) _
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:1 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES Q
IF YES: enter Book [ I
Paged ? and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained Q ,Date Issued
C. Do any signs exist on the property? YES Q NO Q
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:
I
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
o., • _, :" X1.7
•
fv r _ of Northampton • A
a B I d i ng Department ` ` ,
12 Main Street - ! l' -
11 2 1 2N1 Room 100
o � ampton, MA 01060 � .�t
DEPT. OFBUl�n,g t ;x: 13- 87 -1240 Fax 413- 587 -1272 , , E I:it NORTma- • maot, >. , "try,
Aa, , ma . ... • a .
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:
/6 N T)'L C 2 ,3 A 0C- : Lof Unit
A/ /) m w 1 riA ' iC Zone Overla District
@i 5 !; Etm s . District y Cs. District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
fk Jc.hb e `fl ;J /6 �6 fir &/� AL)
Na ( Print) Marlin Address:
Q Ceti 4 r " 74
2 _ Q:;(4 ' °r te+`'` Telepho f Q ,
Signatu l/i q '' ,cJ �'• D�
2.2 Authorized Agent:
I/? w, JO L i 124 .n'" 1 7g/ /3).i > 0 711, - frag , 12^,4
Name (Print) Current Mailing Addr 0)0
.A..,- j--- /6„4 �g 1//'l7
i gnature / Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ° 74/n) 0_j (a) Building Permit Fee
2. Electrical / (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) _
g_S
5. Fire Protection f� 3;
6. Total= (1 +2 +3 +4 +5) �� O� Check Number Q
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
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1.5IsTiRTHERN AVE - BP- 2011 -G0
z #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C.- 023 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- 2011 -0018
Protect # JS- 2011- 000030
Est. Cost: $28800.00_
Fee: $112.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DOUGLAS J FULLER 55955
Lot Size(sq. ft.): 16901.28 Owner: EASTMAN MICHELLE L
Zoning: URB(100)/ Applicant: DOUGLAS J FULLER
AT: 16 NORTHERN AVE
Applicant Address: Phone: Insurance:
17 MOCKINGBIRD LN (413) 572 -4730 WC
WESTFIELDMA01085 ISSUED ON:7/9/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: CONSTRUCT 20 X 28 DET GARAGE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter: t � -j
Footings: ,X Sea 3 & '0' -- /L
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final• �/� -i2,� �,P/
"/ Amp Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: 0 to` q -j C! _CNC✓✓1
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
'".. litchw h,opt444
Certificate of Occupancy C i 7 Signature:
FeeType: Date Paid: Amount:
Building 7/9/2010 0:00:00 $112.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo