25C-187 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 backfd1).,
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 occupancv
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
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.
Date
Address of work
location
, .. . :. ,
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. The Commonwealth of ilfassachusetts
Department of Industrial Accidents
i i,..........„-= in
Office of Investigations
600 Washington Street
Boston, MA 02111
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7 .17.1 ,
. 1 www.mass.gov/dia .
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Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organiza' tion/Individual): C ( A. 1 BA 0.)■/A
.. ,
—Address: ,. .
City/State/Zip: .. Phone.#: • -
. - p
Are you an employer? Check the appropriatebox: • Type of pi (required): 1
• 1. 0 I am a employer with 4• 0 I am a general contractor and I • 6. 0 New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet: 7. 0 Remodeling
210" I am a sole proprietor or partner-
These sub-contractors have
ship andbave ILQ employees .8. 0 Demolition
eniployees and bave ' -
working for me is any capacity. workers 9. - 0 Building additiOn
_ comp.insmance.;_. -.
[No workers' wrap. insurance
10.0 Electrical repairs or additions
. . 5. 0 We are a corporation and its
officers havei-exercised their . 11.0 Phrobing repairs or additions •
3. 0 I am a homeowner doing all work
myself [No workers' comp. nett &exemption per MGL
12.0 Roof repairs . -
insurance require] t ' c. 152, §1(4), and we have no
13.0 Other
employees. No workers'
cninP. insurance required. -
•
*Any applicant tut checks box #1 must also fill out the section belowshovving rworkers' compensation policy information. •
t Homeownera who submit this afftdaVit incHcatin' g 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-cormactmshave employees , they must provide their workers camp. poEcyntanber. . .
1 am an employer that & providing workers' compensation insurance for my employees. Below is the policy andjob site
information. -
.
Insurance Company Name: . • • -
Policy # or Self-ins. Lic. #: Expiration Date: -
. • .
Job Site Address: • City/State/Zip: • - I -
Attach a copy of the workers' compensation policy declaration page (showirtg the policy number and expiration date).
Failure to secure cOverage . as required tnider Sectioic25A c 152 can lead to the iiitPositiOti ofetiminal. 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 wogic ORDER. and a &.e
. .
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Eifeilliations of the Da for biiiiiiiice CoverileierifiCaliOn. . _ _ ._ . — ..,,, _,
I la hereby certifr under the pains- , d penalties of erizay that the information provided nbove_a_truz_and.carrect.______ _.
__ A of
-.,.. , .4I .--
ture: . 4 • --- . . -... - • 1/ ate- . . •
... ----
Phone it: • - -
Official use only. Do not write in this area to be completed by city or towiioffic.iaL
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City or Town: .• Permit/License # .
— .....
Issuing Authority (circle one): -
.1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other . 6- . • . •
Contact Person: Phone #:
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : C U. 1 p t T ( PS f ' W Ata 9 9 3 4
` License Numbe
$/9 !I
Address Expiration Da e
Signature Telephone
f
7/ P/ S A t-z----a o Al" i 43i-13074
9: Re . is re _Home: m i ,.1 ti. a` T" '''';'%' '.4 MENatifiNgi Not Applicable ❑
1S9 7Lii
Company Name Registration Number
Address E p 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 ❑ No ❑
t= arm °° , r + e Y 6n
w
The current exemption for "homeoners" s extended to include Owner - occ ed Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an in ' idual for hire who does n• .ossess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Sectio 08.3.5.1.
Definition of Homeowner: Person (s) who own a parc - • f land , which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attach.: Dr detached structures accessory to such use and/ or farm
structures. A person who constructs more than one 1 : e in a o - year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building • cial, on a form ac ; •table to the Building Official, that he /she shall be
res • onsible for all such work . erforme s . der the buildin • • emit.
As acting Construction Su • erviso our presence on the job site will be requi .• from time to time, during and upon
completion of the work for w.' this permit is issued.
Also be advised that wi • eference to Chapter 152 (Workers' Compensation) and Chap - 153 (Liability of Employers to
Employees for in es not resulting in Death) of the Massachusetts General Laws Annotate., ou ma be liable for person(s)
you hire to :: orm work for you under this permit.
The u. , signed "homeowner" certifies and assumes responsibility for compliance with the State Bui , 'ng Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annota ; I.
Homeowner Signature �,
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing X
Or Doors ❑ j "
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [❑ Siding [0] Other [CI]
Brief Description of Proposed
Work: (C IPCACt PPOf lifter A
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a t ttiW itii if a c c �. 'li ei` I litill9 c i ° V tt h ire:
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 attac z •?
d. Proposed Square footage of n- •nstruction. Dime : ons
e. Number of stories?
f. Method of heating? Fi : • aces or Woodstoves Number of each
g. Energy Conservation Compliance. - heck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlan• . Yes No. Is construction wit' • 00 yr. floodplain Yes No
j. Depth of basement or cellar i , • r below finished grade
k. Will building conf• •• o 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, ♦ 1 t ' 1 " a � as Owner of the subject
property
hereby authorize 5 �'� t' 111Q .
to act on m half, in 11 matters relative !work authorized - by this building permit application
Signature of Owner Date
I CAA 2t M jA 2 A ex , as Owner/ uthorize
A ereby 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.
Cct2 (s 13 /9
Print Name
- '6't, 1 ; 5 i - KA/ A
Signature of Owner /Agent Date
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Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Inc ple Info ! /
Existing Proposed Requi d by. oning r
This col a filled in by
Building DepartmePtt
Lot Size i ma y'
Frontage , - '' '
Setbacks Front I
Side L R:_
L:? R: z a
Rear i 1 I
Building Height 1 1
I
Bldg. Square Footage = i % 1 L 1 P
Open Space Footage % --
(Lot area minus bldg & paved ° _ ____ 1 , ? 1
parking)
# of Parking Spaces I i I
Fill: . ___ e
(volume & Location) i k :1 1
A. Has a Special Permit /Variance /Findin* ever . -en issued for /on the site?
NO 0 DONT KNOW 9) YES 0
IF YES, date issued:;
IF YES: Was the permit recorded .t the Registry of Dee.'s?
NO 0 DONT NOW 0 s 0
IF YES: enter Book r I Page, I 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 Conse ation Commission?
Needs to be obtained Obtained 0 , D. e 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 prope , ? YES Q NO 0
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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
:,
*`t x� s ) ohs _ " ' v
• & 'ty of Northampton s
A B 'Iding Department _ A e A ` , `
�' . 2 Main Street g _ ; :-;
�NSQ . Room 100 , = ,..E,
_ e � � Northampton, MA 01060 4 4 = _ t
phone 413- 587 -1240 Fax 413- 587 -1272 fl '`�
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: (�
2,8 rk tG tt L A N.b /\V f & Map Lot Unit
N ®( A UAL P i o ) / A I \ e"°('° Zone Overlay District
El St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: -
4-A � C j74: ai 1) v∎ di. &-
Name (Print) Current Mailing Addres
/, 'for _ A 1111. t+ic AV d c9/
_ Telephone
Signature 9/ s Z
2.2 Authorized Agent: .
cup (SP\ .�3A2mAr'(� c��VC K %L R
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 f Q 0 (a) Building Permit Fee
2. Electrical , (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) T 35. 0
5. Fire Protection _ /� )
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
r
28 HIGHLAND AVE BP- 2011 -0723
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 187 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 -0723
Project # JS- 2011- 001193
Est. Cost: $8000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CURTIS A BARNABY 99366
Lot Size(sq. ft.): 10497.96 Owner: BATTEN ROLLAS W
Zoning: URC(100)/ Applicant: CURTIS A BARNABY
AT: 28 HIGHLAND AVE
Applicant Address: Phone: Insurance:
157 Cave Hill Road
LEVERETTMA01054 ISSUED ON:3/14/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE ROOF W /METAL
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 3/14/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner