25C-167 •
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 _ofNorthampton 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 insn ion process requires that the buildint 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
- 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
1, 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
., ,r S k ir'
.
The Commonwealth of Massachusetts
Department of Industrial Accidents
ti
5 _ :W Office of Investigations
r h
600 Washington Street
=4.1—= i Boston, M4 02111
�.� www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ,f� Please Print LegibIv
,
Name ( Business /Organization/IndividuaI): L ( fkrk LR � ' tM . 1 6 4 af
Address: I‘ v °% o LI
City /State /Zip: t\ k ‘ dVS D Phone.#:
Are you an employer? Check the appropriate box: Type of project (required): /
1. I am a to er with 4. 0 I am a general contractor and I
y 6. 0 New construction
employees (full and/or part-time).* have hired the sub - contractors
2. t►. I am a sole proprietor or partner-
listed on the attached sheet. 7. 0 Remodeling
. • . and have - o loyees These sub - contractors have. 8. f Demol on
e plo ees and have workers'
working for me in any capacity. Y 9. 0 Building addition
[No workers' comp. insurance comp. insurance. t
required.] 5. El We are a corporation and its 10.0 Electrical repairs or additions
3. I am a-homeowaer-doing-ate we k o fi=s_aave texrcis d -- _-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.]
*Any applicant that checks box #1 must 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.
IContractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether ar not those entities have
employees. If the sub contractors have employees, they nwstprovide 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
formation _ ...
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 $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. ile advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverate verification.
I do hereby.._ '_.% epains ; and penalties ofperjury that the information provided % .ov is_truenudcorrect -___
—
Si .. tore: _ cy qq a ate
Phone #: 4\ 12C t 1 { .1
m Offic»J use only. Donut wTZte in this grin; tie completed by city or town
_ City or Town: Permit/License #__
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector _ _ _.
6. Other r .
Contact Person: Phone #: .
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
S. Registered :Homn=lmprouemenf- Con t+o .., .., := Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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 X No ❑
w
40:Wutrow: Olt
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 jicense, 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 sh tbtures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two yeaOeriod shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form ace table to the Building Official, that he /she shall be
responsible for all such work performed under the building per t.
As acting Construction Supervisor your presence on the job site ill 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 Mass husetts 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 •-sponsibility for compliance with the State Building Code, City of
Nnrtliatriptoni(?r - nadT Weer: a� •. a •* arc • .1 i tts- General - Laws- Annotated.
Homeowner Signature �`
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House E Addition E Replacement Windows Alteration(s) ED Roofing n
Or Doors D
Accessory Bldg. El Demolition E /' New Signs [D] Decks [( Siding RI Other [D]
Brief De n of
Work: ", . t e P cI \ RaOS ff., Alf r4K.V. cOdi
Alteration of existing bedroom Yes No Adding new bedroom Yes N
Attached Narrative . Renovating unfinished basement Yes � No
Plans Attached Roll - Sheet
6a - i"f=Iteinr late a .aiiit•ti addifibik6 eicistik - tiiousltiii 'd ini lete, t ie allo nnnq:
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 wi ' 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of b ment or cellar floor below finished grade
k. Will bui ding 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
of 1�.0 Nt- NAAJ 5ka,t tI/AI 1, , as Owner of the subject
property 9
hereby authorize j (\ '( 1.•.
to act on my behalf, in all ma, : s relay ve to work thorized by this building permit application.
Signature of Owner- Date
I, MSC.: r ' eLtI l .Qt \-414.3 , as Owner /Authorized
.,,,„,,,,,,,„,„.,!!......,,„,,,„,,,,„,,,,,„.
Agent hereby declare that the statements and information on th foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.. / , '„ k
Print Name 1 1
■ a , �i
�/� _t-y
✓\ f V `N& ' Date , 1
Signature of Owner /Agent
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__
Frontage
Setbacks Front
Side L:—__ R: L ; _. R:
Rear
Building Height
Bldg. Square Footage 1 % f._
Open Space Footag %
(Lot area minus bldg aved
parking)
# of Parking Spaces — _
Fill: _,.�.__
(volume & Location) _ ".. _ __, , d
A. Has a Special Permit /Variance /Finding er been issued for /on the site?
NO 0 DONT KNOW YES
IF YES, date issued:,
IF YES: Was the permit recorded at the Regis of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book Page'' and /or Document # '
B. Does the site contain a brook, body of water or wetlands? NO er 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 0 NO e(
IF YES, describe size, type and location:
- D.` — ,kre there an ��o es to or a pions of si ns intone fog tthe' ro ert ? YES 0 NO
YP P g g� P P Y•
IF YES, describe size, type and location:
E. Will the construction activity disturb {clearing, grading, exca ion, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 10 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
Building Department 'L.takpo'de-fy
212 Main Street
Room 100
Northampton, MA 01060
phone 413 - 587 -1240 Fax 413 - 587 - 1272 ; :: ! kIlfi'Av l , fay
APPLICATION TO CONSTRUCT, ALTER,.REP:AIR, E 1OV r'E OR DEMOLISH A ONE OR TWO FAMILY DWELLING
..
SECTION 1 SITE INFORMATION
tie
Property Address: \t", Q� `� I L \ This section to be completed by office
0 tG S( Map a Lot Unit
Zane Overlay District
EIrnSt:District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
SAA 0j1C‘kek ktc,vjj 30 6 PANA. ttif- oti(
Name (Print) Current Mailing Address: slb
Telephone
Signature
2.2 Authorized Agent:
- 1 •sac %1 � i� f
o
ur �;_„ �;�` ' Curren aili Address: L
ity
Signatur- Telephone
SECTION 3 - 'ESTIMATED CONSTRUCTION' COSTS
'i
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building Qb (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. Total = (1 + 2 + 3 + 4 + 5) Check Num 9,2 7 W ,/✓
This Section For Official ! se Only
Date
Building Permit Number: Issued:
Signature: 5—/Z Z 7/ (C
Building Commissioner /Inspector of-Buildings • Date
File # BP- 2010 -1074
APPLICANT /CONTACT PERSON MARK LANDY
ADDRESS/PHONE P 0 BOX 61 ASHFIELD (413) 625 -6999 ()
PROPERTY LOCATION 30 ORCHARD ST
MAP 25C PARCEL 167 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 002-7
Fee Paid
Tvpeof Construction: REPAIR FRONT PORCH & RESIDE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 077431
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER: §
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
...C1251
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
$¢ BP- 2010 -1074
GIS #: COMMONWEALTH OF MASSACHUSETTS
0 250 -167 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 -1074
Project # JS- 2010- 001578
Est. Cost: $55.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANDY 077431
Lot Size(sq. ft.): 8319.96 Owner: MARCHAND SOSHANA & LUKE JAEGER
Zoning: URB(100)/ Applicant: MARK LANDY
AT: 30 ORCHARD ST
Applicant Address: Phone: Insurance:
P 0 BOX 61 (413) 625 -6999 ()
ASH F I E L D MA01330 -0061 ISSUED ON: 6/1/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR FRONT PORCH & RESIDE
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 6/1/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo