25C-197 HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780C :1' 108.3.4 to
act as his/her construction supervisor. The state defines `Homeowner" : , " Person(s)
who owns a parcel on which he/she resides or intends to be, a one two family
dwelling, attached or detached structures accessory to such use . : • or farm structures. A
person who constructs •re than one home in a two-year p - ' . • shall not be considered a
home owner." \�
The building department for ..e City of Northampto Its person(s) who seek to use
the home owner exemption; - to ct as their own co e • i tho supervisor, to be aware that
by doing so you become respon ible for comp ' nce with state building codes and
regulations. The inspection pro .. requires the building department be called to
inspect work at various stages, whi i includ foundation /footings (before backfill),
sonotube holes (before pour), a rou , h b 1 ding inspection (before work is
concealed), insulation inspection (if *, ired) and a final building inspection. The
building department requires these insp - • ons before the work is concealed, failure to
secure these ins • ections can result ' ure to obtain a certificate of occu • an
until the work can be inspected.
If the homeowner hires other trade to perfo work (electrical, plumbing & gas) the
homeowner will be responsible t. make sure ' • the trades hired secure their proper
jermits in conjunction to the bu ∎ ding permit i • ed, and that they get their required
inspections. Failure of the in• idual trades to e the permits and inspections as
required can DELAY the pr., ect until such time the proper permits and inspections are
made
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
Date
Address of work
location
y
. t The Commonwealth ofMassachusetts
Department of Industrial Accidents • ,
5 =,- Mr, " Office oflnvestigations
°j��=
��
•
it, 600 Washington Street
Boston, MA 02111 -
y „ f www.massgov /dia • -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
■ Applicant Information • CG.12 q 15 - 6A {2NA '( 3 `1 Please Print Legibly
Name ( Business /Organization/Individual):
• • Address: - • City /State/Zip: - Phone. #: - • •
Are you an employer? Check the appropriate'boz: YP of ( .Type r'ect r /
4.. I am a general contractor and I P e4
1. I am a employer have hired the sub-contractors 6. ❑ New construction
employees (full and/or parttime). #
-
. 2 I ann a sole proprietor or partner- listed on -the :attached sheet: 7• ❑ Remodeling
ship and have no a :loyees These sub - contractors have S. E Deiroiition • . -
- for me m any andjhave workers'
rking y capacity. 9 IDBuilmg a� ditioa
[No werkcrs comp. insurance
r ed 5. 0. We are a corporation and its 10.[I-Electrical repass or additions •
equa
3.0 I am a homeowner doing all work have work xereised their 11.0 Plummbing repairs or additions .
myself [No workers' comp. right of exemption per MGL 12:0.Roof repairs
insurance required.] t ' c. 152, §1(4); and have no •
employees: [No workers' 13.0 Other r
. comp, insurance required].
Any applicant that checks box #1 must, also fill out the section below showing their compensation policy information: . - . •
t Homeowners who submit this affidavit:indicating they are doing all work and then- hire outside contractors must submit a newafdavit indicating such.
:Contractors that rri••rr this box must attached an additional sheet showing the name of the sub-conaactors and state wiled= or not-thoseer Cities have •
employees. If the sub - contractors bave employees; they must provide their worm s' comp. poky mmber. -
lam an employer that is providing workers' co
ompensation insurance for my einplgyees. Below is the policy and job : site
information. • ' •
Insurance Company Name:.
Policy # or Self-MS. Lic: #: Expiration Date:
Job Site Address: City/State/Z.ip:
Attach a copy of the workers'' compensation policy declaration page'(showing the p9hcy number and :expiration date).
4 —..
Failure to secure coverage,as required uadcr Section `25A ofMGL c 152 can lead the imposrtto r ofcnnnnal peaatties of a
fine up to 51,500.00 and/or one -year imprisonment; as well as civil penalties in the form of a STOP WORK -ORDER and a &_e of up to 5250 00 a day against the violator copy of tuffs statement may be forwarded to the 01ce of
Tnvestit*attons ofthc DIA for insurance coveraze verification. .. _ , .._,_ .;. _._._. ; . .._ :. ... _,�
under the
I
c do hereby certify airs and penalties o _ f p '
P p - ,fpm9�3' that in� ormatinn rovr�ded�cty. P�rvr_aadcor � red .....; _ ...
SiBnattire: e O V 11 / S � y� !� - J • ate,_ , _
4 •
Phone it: . .. • •
- official use only Do not write in this area, to be completed by city or town o fficiaL
City or Town: Permit/License #
Issuing Authority (circle one):
t .'1. Board of Health 2. Building Department 3. City/Town Clerk . 4. Electricaljnspector 5. Plumbing Inspector
6. Other E
Contact Person: Phone #: • .
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Q Alto At (- J Not Applicable ❑ fn
Name of License Holder : CU, t C tJ 6 Alto 9 9 56)k>
k
License Number
l - 7 CAvf +4, 4, ., GZ041O
Address Expiration Date
tE kX ►f- - c
Signature Telephone
9.1 eeistet -Hciinie Imttroiuerner►t =Corifard t r yz_r Ki iM tt ,,..� z ; 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 ❑ No ❑
•1:ri4.- Home' E
The current exemption for "homeowners" was extended to include Owner - occupie • 1 wellines of one (1) or two(2) families
and to allow such homeowner to engage air-individual for hire who does not pos ss a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108..5.1.
Definition of Homeowner: Person (s) who own a pa of land on whi e/she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attac - 4 or det • ed structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a - • ear period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on orm acce 1e to the Building Official, that he /she shall be
res i onsible for all such work I erformed under the b ' din . I emit.
As acting Construction Supervisor your presence . the job site will be required fr time to time, during and upon
completion of the work for which this permit i ' sued.
Also be advised that with reference to • . er 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resultin ' ' eath) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for yra 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 D Replacement Windows Alteration(s) ❑ Roofing Mil
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other [D]
k
Brief Description of Proposed R6 As70 f
472,41 ,,,,(4,,,47c
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa t lei' iv ii iidfaViddi o to`e iiiinci i661iii`g m ttie:foitaw a:
a. : .f building : One Family Two Family Other
b. Number of ro• • in each family unit: Number of Bathrooms
c. Is there a garage attache. '
d. Proposed Square footage of new con . ction. a imensions
e. Number of stories?
f. Method of heating? ireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Massc' - Energy Compliance form attached?
h. Type of construction
i. Is construction within 101 . of wetlands? Yes No. Is construction within *1 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 .
1 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
I, -41-‘1, (Jr +e e , 1.9 , as Owner of the subject
property I
hereby authorize a t `1 ' S '6 et, r -- I't _/may
to act on my behalf, in all matters relative to work authorized by is building permit application.
6'24.4 cX Ce_e__, 4 I I
Signature of Owner ate
% 1 (/!j V/ - S A R N AO . , as Owner /Authorized
N ( Agent hereby declare that the statements and info tion on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Al % - 1g
Print Name
1.Yiv S /S ri .....„Vi...„4".."/
Signature of Owner /Agent Date
. f
/
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomp formption
Existing Proposed Required b nin
This column to fillei by • 4
Building Dep ° , .
", A. 4
' Lot Size 3 .._ " eta;, 1
Frontage .. , ,_.._._..._.
=s
Setbacks Front i i ', J
Side L:1 . R: L:i i R:' i fl j , i i
Rear = a
t --- --- -
Building Height 1 -- ---- [_
/
Bldg. Square Footage i 1 F-1 % i a /1 i
1
Open Space Footage % ,-- ,
(Lot area minus bldg & paved I i 1 1 -1-1
parking)
# of Parking Spaces ? ' --
/
Fill: 1
(volume & Location)
A. Has a Special Permit /Variance /Finding eve I•een issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the ''egistry of Dee s?
NO 0 DONT KNOW 0 • s 0
IF YES: enter Book I Page€ and /or Document # ? r __
B. Does the site contain a brook, bo. of water or wetlands? NO 1111 DONT KNOW Q YES Q
IF YES, has a permit been or eed to be obtained from the Cons- ation Commission?
Needs to be obtained 410 Obtained , D. a Issued:
C. Do any signs exist on the p • perty? YES Q NO 0
IF YES, describe size, ty•e and location:
D. Are there any proposed hanges to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size type and location:
E. Will the construction acti ity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 a•re? YES 0 NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
G
� City of Northampton � ® � �� 7,7,17-X-7,
�� �����
�► Building Department Z . - (k . ' � . " u, : t
212 Main Street m
,
Room 100 = �
.gyp �' ` Northampton, MA 01060 ,
,:''' ' phone 413 - 587 -1240 Fax 413- 587 -1272 ° g t ` s l :, £ a
� f
2
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
6 S �o �� 14 5T- �(. Map Lat Unit
Zone, Overlay D
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
( 2.1 Owner of Record:
41� l y �' it,��,- fi t,,/r� fi n , �J% 6
Name s�Print) C u rrent Mailing A dyes
4 -1 � �'� `� Telephone
Signature
,X 2.2 Authorized Agent:
APD (
Name (Print) Current Mailing Address:
Signature 6 , 4i . R ,i_ a,. / �� /-1 5 jt/ 1 5 Telephone t-{ a j� .�
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building W (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction fro (6)
3. Plumbing Building Permit Fee
,
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number / 6
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
65 NORTH ST BP- 2011 -0815
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 197 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 -0815
Project # JS- 2011- 001337
Est. Cost: $1000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CURTIS A BARNABY 99366
Lot Size(sq. ft.): 6403.32 Owner: CREELY ANN & BRIGITTE PAROT
Zoning: URC(100)/ Applicant: CURTIS A BARNABY
AT: 65 NORTH ST
Applicant Address: Phone: Insurance:
157 Cave Hill Road (413) 687 -8876 0
LEVERETTMA01054 ISSUED ON:4/11/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: STRI P & 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 4/11/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner