25C-165 (2) 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 fandly
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
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.
Date
Address of work
location
. .
,,-
. ... ' ,
.. ,
. . •
The Commonwealth opfassachusetts
Department of Industrial ACcidents
r Alk . r,. ... ■,., .,-...■•• gi
Office of InVestigationS
=.TEL.......—. 1 600 Washington Street •
Boston, MA 02111
. . .
, ••,...,,,,,,z—,
• • , , www.mass o-ov/dia . .
. .,
•
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers - - •
Applicant Information - Please Print Legiblv
• • . ......:::-: :
Name (Businesi/Organization/Individual): . . • 1
. . .
• . ,. -
• • Address: ,. • -
. .
City/State/Zip: •
- . • Phone.#: - • - .
•
Are you an employer? .Check the appropriate'box: • . .Type of project (requir ed):. i
1. EDI am a employer with .. 4.. 0 I am a general contractor and I
6. 0 New construction
have hired the sub-contractors
employees (fall and/or part-time).*
2.4 I arii a Sole proprietor or partner- listed on theatta.ched sheet" 7. 0 p.emodeling . .
These sub-coniractors have.
ship ancl have no e.:4-Ioyees -8. 0 Deirblidon • . * "
working for me m any ca p a city. iIM.I.P_YPPP-4 W Otters' 9 . s.--,.... --,,:::..,?...,....- —__' • '
9: 0 Stlilrilfig a . •
[lskr workezre enroll. insuiance- • - .comP--kmaranci---;-•:. • - .- . - .. -....,-----: , . .. s . .
required.] 5. 0 We are a corporation and its 10-11 Electrical repairs or additions
• 3.0 I am a homeowner doing all work ()fa, cars haire4 .61 • 11.0 Phi:thing repairs or additiOns .
myself [No workers' comp. • right d'.exercTition per MGL
12. 0.Roof repairs • . -
insurance required.] t ' • c. 152, §1(4), and we have no •
expp [N wor k& s , . • ' 1q.[} cithet
• • . , • :.
, .
comp. insurance reqinted.j. : • , - • • • : .. -
. • . . - .
" *Any applicant that checks box tamust also fill out the seenon belay/showing their -compeMsation policy information
t Homeownera who submit this affalaVit.incfit'xi4rii they are doing all work and then hire outside coati-x10ra must submit anew affidavit indicating such.
Contractors that check this box must attached an additional sbeet showing the name of the subcontractors and 'state win:titer ornotthose.entities have . •
enaployees. If the sub-contractors baie employees, they mast provide their wOrkers comp policy number . ... ..
. . .
• •14in an employer that &providing workers' compensation insurance for my einplayees. Below is the policy ad job site
information. . -
. . .
.. • . . • .
Insurance Company Name: . . • - - . .
. .
• •
. .
• .. . . •
. • . . . . - . . . .
Policy # or $elf-ini. Lic. #: • • Expiration Date: - . . .• I . ,
. • . •
. . .
. . . , . .. .
. r —
Job Site Address: - • ' • . : • • . ' City/State/Zip:' - • . • • • . , - ..
-Attach a copy of the worker?' compensation policy declarailon page (showing the policy nuMber and date).
. . ,
Failure to sectre . ctiverigii reitiiiit8'd'inicter $eCtiont25A .. difi lead to the iinPOsitiiii Ofaitiiiiial penalties of a
fine up to $1,500.00 and/or one-year iiiipiisonme:4' as well as civil penalties in the form of a STOP W9P.Ic9xplat and a fine
• of up tO $250.0 a day against the violator. Be achr#edtba.t a copy Of this statement rimy be forWardedth the..0,ECC•of . . • .
- EiestiiiiidisciftliiDa. for nstiratieeCovire Vilification. . . . . ' _,. . ;.',.--, .•;Lii....: ':.,:,....:-....,.:_,,..„..: .... ,..,... .. _....,
fir< i ij:IFC e78 Wri 44 t A' e' i a u : 5 ; et . n . 4; r; i it 1 e' .i. 4; ; r jiii; mat . the iiitirrO n . p4O V ii I i. iii fii i / 1.e_iiiniiii;ditorrizet.' . .
I'11-4. •••tat _ .... a.:--- -- _ At. , • -• • . • Date; " 0 -1 )1
.. • . . ' ' •
- • - I • • r . - .
Phone it: • . • • • •
, - - , ' • •
: - Official use only. Do not write in this area, to be co mplet.ed by city or townofficiaL
• . . : • , - • . .
. .
. • • .
City or Tovvu: .- Permit/License #
--....... .
Issuing Authority (circle one):
.1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electricalpypector 5. Plumbing, Inspector
6. Other , • . .
Contact Perscin: Phone #:
• -
. •
- .
SE ION 8 - -- CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: C I Not Applicable ❑
Name of License Holder : l nc - NiNr,� 1 \ t (o1 +�
License Number
1 fa v,.)Qc.., fi. yk.,kvii rC* 0 r0 )Q( to a
Address Expirati n Date
` I) c —D X., S 19 LK
Signature Telephone
.,:Reuistere l..tiiairhe improvetnerit C ontractor ,. , „.,.
i . ;w . _ ,. A, , . "� u ` „ , w:, Not Applicable ❑
t s l > ikV S 131 loH i p
Company Name Registration Number
�
Addre ��� c-\ a on D a t I
Exp e
_ti p ).)\ i , Q 1 0 r) j`1 Telephone .liq ” ° 1 1 - 1S -
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 ❑
11. - Home er Exemption'
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, 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition [] Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [El Siding [D] Other [0]
ief Description of Proposed
Work: Sic ' Q r cGF oM.. 101/4.4 SO `..i.ost4 Shlnq�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa :' Ne�nr hd�lse a td ar a i�difi oin;to`'ezisfir a t Dtrs�nq ct�mi�tete "the following:
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
, as Owner of the subject
property
hereby authorize 1 0 kiA t 1
to act on my behalf, in all matters relative to work authorized by this building p it pplication.
S ignature of Owner Date
\ - c i , 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.
Signe nder the pains and penalties of perjury.
P nt Nam
Nr`r&Q ft" (1
Signature of Owner /Agent Date
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
Frontage ;_ _.._.
Setbacks Front i I i
Side L R:.______' L _..._ R:'
Rear ,_____. .
Building Height t
Bldg. Square Footage i ! % r.rni i c
Open Space Footage _ % ----
(Lot area minus bldg & paved L
parking)
# of Parking Spaces
Fill: r ------ —11--- ...,w ., ----- ..e H ..� .
(volume & Location) t --
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
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 ' i Page ' and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q ,Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Y
f -
''^'}{° +*may yip'+ �{
City of Northampton 4 t f , if �'1 . ; a s
! — ` -_ __ I Building Department a :a D� y * ItiVi v %! ,
�EC _ 212 Main Street Se e 0, Va# .' � i k
Room 100 i i I i7 z i *i
MAY 12 Lu I I Northampton, MA 01060 a ' ran 1 ��_ � .
phone 413- 587 -1240 Fax 413- 587 -1272 , ' , � $. y��71\ ry -
12 � � R x as { . F
DEPT OF BJILDiN i�t,aG � CNS �,,, �a �v > � r ..,. �� y_,� ��,
NOHIHAMI'i ON MI
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
CTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
c r a cst_No & sk Map _ Lot Unit `-
`'` *-or Zone Overlay District
Etna St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
P e- - er g i- e I 2,1c I4Mkers - .R4 Pe /lw ktift
/ Name Print) Current Mailing Address:
€4C3 1` Telephone J 7......c.---
/ `� - "7 — 7 t j 10
Signature
2.2 Authorized Agent:
i � nocroS i Di � •es�: 'Mo a��.j (wP O t o 3c
Namee (Print) Current Mailing Address:
L____ cYNCj 9 S Is u1 - 3cr A
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Ite Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
t-(, 000 , t
2. Electrical (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) Check Number Y
This Section For Official Use Only
Date
Building Permit Number: _
Signature: !/ t` � / v ' /7
® 4
Building Commissioner /Inspector of Buildings Date
20 ORCHARD ST 4 BP- 2011 -0935
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 165 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 -0935
Project# JS- 2011 - 001519
Est. Cost: $4000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THOMAS FIL 069036
Lot Size(sq. ft.): 8799.12 Owner: BITTEL PETER J
Zoning: URB(100)/ Applicant: THOMAS FIL
AT: 20 ORCHARD ST
Applicant Address: Phone: Insurance:
127 WEST ST (413) 584 - 3945
HADLEYMA01035 ISSUED ON:5/12/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 5/12/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner