25C-099 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
D o V'A1� a1 derstand the above.
(Home owner /resident's signa re requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date \ 2 t I < (
Address of work
location S 1 f A' __
NJ avLo A - D / D( b
. ..,
. The Commonwealth of Massachusetts
Department of Indus Accidents .
A I I k "' Milli= V=17:1 drj
Office of Investigations .
0 =.... i=.. .t.
600 Washington Street
Boston, MA 02111
e' *. www.mass.gov/dia
I
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers -
Applicant Information - Please Print Legibly -'
Name pusiness/Organization/Indivirinno: I) C b 0 v I Th i ( a. Ct. 5
A
- • Address: . 5 6y-a km.t A- v--c-
City/State/Zip: 1\-) ON P L i 1 3 - S1 1 3 0 3
Are you an employer? Check the appropriate box: Type of project (required): "
•
1.0 I am a employer with 4. D I am a general contractor and I , .. • 6. U New construction
employees (full and/or part-time).* have hired the sub-contractors
lis-ted on the attached sheet: 7. 0 Remodeling
2. El I am a sole proprietor or partner-
These sub-contractors have
• ship and have no :).loyees .8. 0 Demolition
working for me m any capacity . emiiloyees_andhave workers 9. _osiiilai.;,_ ddxfi
[No workers' comp. insurance
required] - . 5. D We are a corporation and its 10.0 Electrical repairs or additions
3.)?, I am a homeowner doing all work officers havexercised 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 Other
comp. insurance required.] - -
• .
*My applicant that checks box #1 must aL93 fill out the section below showing theirworiorrs' convolution policy information.
t Homeowneri who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating sarh .
*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 poficy number.
Jam an employer that is providing workers' C ompe.nsation 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 date).
Failure to secure coverage as required inidei: Section 25A 'of MGL c. 152 can lead to the iinpOsitibn eel 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 WOBX-O.RDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy etas statement may be forwarded to the Office of
tidbits of theDIA foriiiuraitce cove VerifiCatiMi _ . . . . ..-
_ I do herekv_certi:67 under the pains and penaltie s ofperjray that the infermationprovided aye _and_corrPci.
si ...
. t..e, p ( ), IA : 4 , Zil 0 - - • /. ( /
• / - Date: . , •
—
Phone #: l i 1 -; - 5 cr'A 9'3 0 • - - • 0 .
- Official use only. Do not write in this. area, 10 be completed by city or townafficiaL
• .
• City or Town: .• Permit/License # • _ .. _ .
Issuing Authority (circle one):
.1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical 5. Plumbing Inspector
6. Other , .
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
Licen Number
Address Expiration Date
Signature Telephone
B ; R" egisterel Ratiliitilliroitemiiiat iti�dc y ; 1 W ,; 1 . 1 ; i ..,. Z ,, Not Applicable ❑
Company Name ' = • istration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c.15a:§ 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 ❑
The current exemption for "homeowners" was extended to include Owner occupied Dwellines 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 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 buildine 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 I—
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) UL-°p .S
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [D] Other)
Brief Description of Proposed r-
Work: 1J SIALt/ 1f J (00b 510 vl�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a EfNe i shoos nd or a c o xistlnq ho since comDl tetr lta na:
a. Use of building : O ne Family Two Family Other
b. Number of rooms in eacfr mily unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new const ion. 1 imensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mas- eck Energy Compliance form attached?
h. Type of construction
1. Is construction within 100 ft. of wetlands? Yes No. Is constructio ithin 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
I , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work autho - • by this buildin it application.
Signature of Owner Date
1, P 14. CO a er/ uthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to th my knowledge
and belief.
Signed under the pains and penalties of perjury.
Printt a S
/
Signature of Owner /Agent D e
.a+
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 r
Frontage ' ' 1 1
Setbacks Front ''.....,1 ( ;
Side L: £ FL= L l i i s
Rear i
i
Building Height
I , 7-1
■ I ..
Bldg. Square Footage [ ` I 1 —I 0/ 1
b
Open Space Footage %
(Lot area minus bldg &paved E # _ r
parking)
# of Parking Spaces E ~ ~ - -
Fill: } , } vi (volume & Location)
A. Has a Special Per it /Variance /Finding ever been issued for /on the site?
i NO 0 DONT KNOW 0 YES 0
IF YES, date issue :f 1 �
IF YES: Was e permit record - • .t the Registry of Deeds?
NO 0 DONT KNO . Q YES Q
IF YES: enter Book I Page and /or Document #
B. Does e site contain a brook, body of water or well. •s? NO Q DONT KNOW 0 YES Q
IF ES, has a permit been or need to be obtained from t' : Conservation Commission?
eeds to be obtained Q Obtained Q Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location: I I .
D. Are there any proposed changes to or additions of signs intended for the property ? Y Q NO Q
\ --1
IF YES, describe size, type and location: _1
J
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a comrro 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.
•
.+.
City of Northampton
Building Department . ° a 1 t.,
�H Room 100
\11- '1»' 212 Main Street
$, 4
^� �. f & f p ,U fit,
-ht rthampton, MA 01060 :: : ii. ; � °
phone 413 - 587 -1240 Fax 413 - 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
S Gra v -1 ,A -e_ Map Lot Unit
D Lr a VV � ¢ T Zone Overlay District U O O v Elrrt St `'District . CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
T � bo r aS 5 CrY - i N ' 1 11-\ Name ( H--(.-/-t S-
Mailing Address 13 5 o `"I 9 3 0 3
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building' Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6) ,
3. Plumbing Building Penult Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) / 9 ot� , LiU Check Number I D ` 3 1UU
on For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
5$ 1 .: BP- 2011 -0651
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit # BP- 2011 -0651
Project # JS- 2011- 001051
Est. Cost: $1900.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 8319.96 Owner: HAAS MATTHEW K & DEBORAH K KRISTEN
Zoning: URB(100)/ Applicant: HAAS MATTHEW K & DEBORAH K KRISTEN
AT: 55 GRANT AVE
Applicant Address: Phone: Insurance:
55 GRANT AVE
NORTHAMPTONMA01060 ISSUED ON:1/24/2011 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:
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 1/24/2011 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner