25C-247 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
jerniits 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
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
7
. .. • ' . .
. .
. The Commonwealth of Massachusetts
,-- Department of Industrial Accidents .
Office of Investigations •
r • B ..- Es t ii,
600 Washington Street
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.1/4 --..-..... Ais Boston, MA 02111
- www.mass cvv/dia ,
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- Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Please Print Legibly
Applicant Information
Name (Business/Organiiation/Inciivirinno ) 0 :
• • Address: q H i 1 k <, ) ' ol z. i.J ,- • .
1
, i
City/State/Zip: ilot I a.4.., AI A ot0 3 5 Phone.#: 514 —5 g' L
i
•
. ,
Are you an employer? Check: he appropriate box: - Type of project (required): /
1.0 I am a employer with 4.. 0 I am a general contractor and I
6. 0 New construction
sub-contractors
em have hired the ployees (full and/or part-time).*
2. 13 I am a sole proprietor or partner- listed on the attached sheet 7• 0 Remodeling
•
These sub-contractors have
. 1... and have D.0 =plOyeeS S. 0 Demolition
working for me in any capacity . einl)loyees_and have workers' ... •
• 9. 0 Building additiOn
[No workers' comp. insurance
5. 0 We are a corporation and its 10. repa
required.] irs or additions
3. 0 I am a homeowner doing all work officers havemercised their 11.0 Plumbing repair' s or additions •
myself [No workers' comp. right of exemption per MGL
12j2rRoof repairs . •
insurance required.) t • c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
• comll nasulanc e required- J • •
*Any applicant that checks box #1 must also fill out the section below showing their wori=s' compensation policy information. --- .
1. Horneowneri who submit this affidait indicating they are doing all work and then hire outside txmtractors must submit a new affidavit indicating such.
1 Contractors that rbt;ek 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-contractorshave employeeS, they must pro their workers comp policy number.
1 ant an employer that is providing workers compensation 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 expiration date).
Failure to secure coverage . is required toider SeCtiOir 25A of MGL c. 152 can lead to the iraPosition ofcal 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 WORK ORDER. and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
eitiiitioniof the DIA faiinsttinc e coverage ireiificifiiiii:
_ I do herekycertifr under the pains.and penalties ofperjray that the informalionproviderLaboveirinte_and_correct..________
Siat / j ,
snure: --ill."--A---„ —'" - - - ' " --- - — i; ,
49/1, - Dath: 9 5 - . Li • . ,
-
Phone it: 5 yet 5"yr . .
. -
Official I use only. Do not write in this area, to be completed by city or towneiciaL
• . .
City or Town: • Permit/License #
Issuing Authority (circle one):
.1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector
6. Other ,
Contact Person: Phone #:
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ) U „ I., vi. '' . /� CS lid CI /
License Number
t 1 tscci - He(d(ev -a~7 - j)
Address Expiration Date
S / 99
Signature Telephone
17: ro < . ` °1,. 1M ; Not Applicable ❑
v =,.A (A ` .� I (v1 / Di 70 ' 7
Company Name Registration Number
- 1 IIIS,'cIe 02 r Jc,d k t 7 6 -ay - I u
Address Expiration Date
— ti /`' 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 ❑
1k, ;hme et . ,ptioi
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'dw.elling, 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; 'tirtaform 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 is d.
Also be advised that with reference to Chap 52 (Workers' Compensation) and Chapter 15'i of Employers to
Employees for injuries not resulting in ath) of the Massachusetts General Laws Annotated, you maybe ' le for person(s)
you hire to perform work for you er this permit.
The undersigned " homeowne " certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinance tate and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Si ature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all- applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors El
Accessory Bldg. D Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [0]
Brief Description of
Proposed II f �� f ` r lG C -'
Work: 5r CALte ∎cti c ,A C/ 'tC p .
Alteration of existing bedroom Yes A No Adding new bedroom Yes x No
Attached Narrative Renovating unfinished basement Yes / ` No
Plans Attached Roll - Sheet
sa gii fi its 'a iid >r ai iiti l e xlti' aq tau is n ii iiii a if f oitc ina
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
1, J OL V1 120 (' C 1 t1 , as Owner of the subject
property
hereby authorize 1 'On C V i 1 Ci
to on my behe, in all matters lative authorized by this building permit application.
Signature ner Date
I, j 001 laC V t ''^ 1 (-1 , as Owne uthorized
t hereby 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 enalties of perjury.
i D'''' Wti% ,/ 101"
Pya/ne 7
Signature of Owner /Ag t 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 Siz rn.
Frontage ! i 1-- .-- ---- ---- -. € 1
Setbacks Front i 1
Side L: T ' R:'.___J L: I R:1 1 s
Rear 1 1 I
Building Height =
Bldg. Square Footage t %
1
Open Space Footage $ % .
(Lot area minus bldg &paved i__..._.J i 1 f = I-1
1
parking)
# of Parking Spaces i i ~—
Fill:
f
(volume & Location) ` i.
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book P agel I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
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 Q 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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
V •
it a . :' ® .rop i
City of Northampton n 7 - , , s z
Building Department " i.�
212 Main Street s
Room 100 B
Northampton, MA 01060
2 'phone 413 -567 -1240 Fax 413- 587 -1272 4 Sr'
t J f : 7 �.Y..... '- i„"
■ l
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
Map Lot Unit
Zone Overlay District
Elm St. District' "' CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
30 60L'giCk , f l 0( (1 fl OO 'ICI
Name rint) i) Current Mailing Address:
(0c,— ,k Telephone
Signal e
2.2 Authorized Agent:
7-() (II 4 .1 / 4 rl 9 c� /'l / 1 5 c .� if
Name Print) Current Mailing Address:
, t 1)
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 Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) S y90, 0 0 C heck Number 0 ti 3 -�
f
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
14;;QLP`MAY RD ta BP- 2010 -0963
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 247 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 -0963
Project # JS- 2010- 001425
Est. Cost: $440.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: QUINLAN BUILDERS 011289
Lot Size(sq. ft.): 20124.72 Owner: BOBALA JOHN J & KAREN A
Zoning: SC(97) /URB(4)/ Applicant: QUINLAN BUILDERS
AT: 19 OLD FERRY RD
Applicant Address: Phone: Insurance:
9 HILLSIDE DR (413) 549 -5474 0
HADLEYMA01035 ISSUED ON:4/29/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE METAL 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 4/29/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo