25C-052 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 hi 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, 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.
_ ___:. _____ .____. _
Address of work
location
. . f 1- w'
The Commonwealth of Massachusetts
'
Department of Industrial Accidents
1-7-9"'r..-:—.7..? Office of Investigations
i , i 600 Washington Street
_1 -' = ' Boston, MA 02111
- www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business / Organization /Individual). , ti tCv ?
Address: 2L-6 ecic-t- -f-A---- .
r
City /State/Zip: `1 ' t, ' p J, V Phone. #: S 7 7 2 `5/
Are you an employer? Check the appropriate box: Type of project (required):
1.0 I am a employer with 4.. 0 I am a general contractor and I
employees (full and/or part- time).* have hired the sub- contractors 6. ❑New construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
hip and have . no en loyees These sub - contractors have 8. ❑ Derdolition
working for me in an c aci employees and have workers'
Y aP tY- 9. Q Building addition
[No workers' comp. insurance comp. insurance.:
required:] 5. E We are a corporation and its 10.0 Electrical repairs or additions
3. El I -am -a homeo-waer -damg bvo_ rk- -- - -- - officers ha r ZRexcised their _ —I -1.0 glurnbi% 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 #1 m also fill out the section below showing their workers' compensation policy information. .
t Homeowners who submit this affidavit indicating 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 whether or not those entities have
employees. If the sub-contractors have employees, 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 Company Name:
Policy # or Self-ins. Lic. #: Expiration Date: -
Job Site 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 $1 and/or one -year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to $250.00 a day a • aiast of "olator. to advised that a copy of this statement may he forwarded to the Offir:r of
Investigations of the D - . • unance coverage verificatiga -''
I do hereby certify . , , , , , , pen • . , perjury that the information provided _above: ue_and_correct. __ _ _ .
,MI AilrAre S �` f / Date:
Phone #: .„. ( _
--- 7 - 7 - - 7
i . - Official use only. Do not write in hzs_areu, to -be compted oy city or town officiaL
City or Town: Permit/License #_
Issuing Authority (circle one):
4: Board of Building h Healt 2. ng De - artment 3. City/Town /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
- - -- b . _ P t3' � �p tr
6. Other r
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES ,
8.1 Licensed Construction Su rvisor: -gyp O Not Applicable ❑
Name of License Holder : J< (} ) 2 -7 ( C)
License N mber
2 - -- -- i 7 77 t(
Address Expirat n Date
Si• at f Telephone
9.. Reclistered Home nitirouert'ientGontraetoi: ' , iiii , da:Z .4, .' .. Not Applicable ❑
) 7�� f/
Company Name Registration Num r
Oi i' LeA Address ExpiratioDat
v ( ) Telephone
1 J
_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 ❑
,r,
and to me llow such P homeo an individua e de _4,r--
lWde Owner occupied Dwellings of one (1) or two(2) families
who does not possess a license, provided that the owner acts
as supe ' - isor. CMR 780, Sixth Edition Sec 108.3.5.1.
Definitio 1 ■ f Homeowner: Person (s) who • - a parcel of land on which he /she resides or intends to reside, on which there
is, ui is iiiteii. d to be, a one or two fa dwelling, attached or detached structures accessory to sunh Imo and/ or farm
structures. A p , on who construc • ii ore than one home in a two -year period shall not be considered a homeowner.
Such "homeowner shall submit e the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all s i h wo - . performed under the building permit.
As acting Construction pervisor your presence on the job site will be required from time to time, during and upon
completion of the wo - for . hich this permit is issued.
Also be advised t.. with refe - nce'to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for ' juries not resul g in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to , -rform work for you er this permit.
The un• signed "homeowner" certi • and assumes responsibility for compliance with the State Building Code, City of
`+: mpton • r •trances, _ a e . • . • ,- - - 4-1-Laws-Annotated.
omeowner SIgnature
r
s
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House 0 Addition 0 Replacement Windows Alteration(s) ❑ Roofing n
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding [O] Other ]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
e f tstM: 6tise anrd -or ac ii loitio,exittinq fiioustnq .`.coirmiiete'Ahe..folioiNlnq;
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
1, 1.Q X cv 1 l l k ( _V f , as Owner of the subject
property �L
hereby authorize
J
to act •n my behalf, in all ma er relative to work authorized by this building permit application.
1 Signatu - of Owner Date
I, ` � ,, 'j V�L2 J J , as Owner / ' uthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of ' knowled• -
and belief.
Signed under the pains and penalties of .
i
Print Name , e ,
./ ce. a� — -
Signatur- of • ner /Agent Date
. I
Sect' n 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
L t Size ._.__ _ .
rontage
getbacks Front
Side L __ R:1 ___. L:________ R:',______
Rear
Building Height
Bldg. Square Footage — 1 %
Open Space Footage %o
(Lot area minus bldg & paved E
parking) 1
# of Parking Spaces - •- — µ°- --`
(volume & Location) -- -- it z.
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES
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 Page? and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES
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
IF YES, describe size, type and location:
I.
"=T "`T D. a re a any propose• c anges to or a. salons o 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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
. , .
• +sl if Sew ( ,, x
-� ' City of Northampton t aw`s ® P - 9 � T,
ti
Building Department O ▪ 17 e rt , m
'212 Main Street t . 9 l qua - � g � , „s E
P � Room 100 r - _ ' ,4� � @ t �_ i
\n`,; Northar ipton, MA 01060 t DS � � f £
�� phone 4-14-587-1240 Fax 413 -587 -1272 �
,.,. mow - � �. .+ 4 ,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
i
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
� <�'
� L__‘ KJ COL Map Lot Unit
Zone Overlay District
!w ► / /1459— Elm st District CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 1
2.1 Owner of Record:
d
-- P‘k4Y\-c\-F404- - .-FIA . e-r IJC)i - \'iital.f40Ai (
Name (Print) Curr Mailin Address:
a Telephone
- 'Signature
2.2 Authorized Agent: / ^
n t k e 5)- '
Name (Print) 97 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 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of ‘ \ \.>c � Construction from (6)
3. Plumbing �� Building Permit Fee
4. Mechanical (HVAC) ' / ,iiri 5. Fire Protection \
i 0 y 6. Total (1 + 2 + 3 + 4 + 5) Check Number `'
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
55 LINCOLN AVE BP- 2010 -0542
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 052 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 -0542
Project # JS- 2010 - 000761
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. ('lass: Contractor: License:
Use Group: SHAWN FOREST 080296
Lot Size(su. ft.): 10497.96 Owner: FLETCHER ALEXA
Zoning: i_IRBf 10P)i *can t: SHAW FOREST
AT: 55 LINCOLN AVE
Applicant Address: Phone: Insurance:
17 EAST ST (413) 527 -7258
SOUTHAMPTONMAO1073 ISSUED ON:11/18/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WOODSTOVE
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: OK 1 02 -7-0g &/+'l
THIS PERMIT MAY BE REVOKED BY THE CI Y OF NORTHAMPTON UPON VIOLA. ION OF
ANY OF ITS RULES AND REGULAT • NS.
.ate .' - ,-� /
4.
Certificate of Occu •anc , L f/ ' si nature:
FeeType: Date ' aid: Amount:
Building 11/18/2009 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo