25-026 •
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
• . • • • • • - • • • - . • • •sszcessxequires 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
----- - - - - -- perm its -in- conjunction.. to_thebuilding 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.
-
Address of work
location (? c) c tz r b M Lt Lk
frvi
Ai r 0 co n
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•
The Commonwealth of Massachusetts
Department of Industrial .Accidents
■ Office of Investigations •
1111=1.11= MMIOW
=1:XL■M, 600 Washington Street
, Et:1
• Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrician.s/Plumbers
Apnlicant Information Please Print Legibly
Name (Business/Organization/Individual): c. L. A rif 'JA A" r"
Address: j
City/State/Zip: I' -0 0%. /Vt Phone #: e /7 -z c 7 KY 2
Are you an employer? Check the appropriate box:
Type of project (required):
1. 0 I am a employer with 4. fl I am a general contractor and I
6. New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet
2. 0 I am a sole proprietor or partner-
These sub-contractors have
ship and have no e-rployees 8. fl Dernovion
employees and have workers'
working for me in any capacity. emp 9. D Building addition
[No workers' comp. insurance - comp. insurance.t
quired.] 5. 0 We are a corporation and its
10.0 Electrical repairs or additions
3. a a.na a-herneewner-doing-all-work officers have*xercise_d_their_ Plumbing repairs or additions
right of exemption per MGL
nyseLf [No workers' comp. 12.1=1Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. No workers' 13.D Other
comp. insurance required.1
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information_
t Homeowners who subrnit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1 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--contractors have employees, they must provide their workers comp. policy number.
lam 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 as required under Section 25A of MGL c. 152 can lead to the imposition of aiming penalties of a
fine up to SI 500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of to S250.00 a day against the violator. Fle advised that a copy of this statement may be forwarded to the Office of
Investizations of the DIA for insurance coveraze verification.
I do hereby certifi under the pains and penoiriPs of perjury that the information provided abovels_true_antLcorrect.
Si -- Ze)
' 'ture: ate:
Phone #: •
use only. DO ziof riffle thifiiiid, be eotnpfeted ky city or town ofiiciaL
City or Town: Permit/License #
Issuing Authority (circle one):
• Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical I I iector 5. Plumbin? Ins ector
6. Other
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
9..Reqistered .Home lmprovementContra`ctor h a. _.,,I � „ Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
_ SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G 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 ❑
a
` .g'I1om O nrd em t
T_he_current_exemption for "homeoivners" 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
ort ampton - Or i mances, a . n. . . `" • . Wetts— General -Laws- Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House E.] Addition ❑ Replacement Windows Alteration(s) Igr Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [1::1 Siding [D] Other [O]
Brief Description of Proposed
Work: / t- t /` v J f - i' R-. K` r 4 i, c k n r , g, 4_ 1., rc., /:► !-'t
Alteration of existing bedroom Yes �o Adding new bedroom Yes __ No
Attached Narrative `` )) Renovating unfinished basement Yep
Plans Attached Roll - Sheet
sa. ift4evii house and.or actdittotito existing hauslnq;= Complete .tt a following:
a. Use of building : One Family Two Family Other
-b. Number of rooms in each family unit: Number of Bathrooms �.7 '
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? �*, T Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth 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 'ty water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject
property
hereby authorize ____._.._._.__.,. ...... , .
to act on my behalf, in alp lattVe to work authorized by this building permit application.
Signature of Owner Date
1, - -.. -- -- f , as Owner /Authorized
Agent heraet;iaie tha a 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.
R ► ez, r`�1 LJA —k c n
Print Name J
Signature of Owner/Agent Date
f .
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 :..... _. LL__.__ R:_____.;
Rear ' _ J
Building Height
Bldg. Square Footage 1 . _ _ % L.
Open Space Footage , ' , %
(Lot area minus bldg & paved - ---...: _
parking)
# of Parking Spaces
Fill: / �.A
(volume & Location) — - ._ -...• / --- ------ _ •.
A. Has a Special Permit /Variance /Finding eve been issued for /on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:';
f',__...
IF YES: Was the permit recgfded at the Registry of ' -eds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Boo ° M
k E Pagel _ E and /or Document #
B. Does the site contain a brook body of water or wetlands? No 0 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
----- — C. "Are tFiene any proposed c ranges to or a rtions o signs inten ed for` property ? YES 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.
� a
City of Northampton state Pefirttt
Building Department C t t�vevvay, it�
212 Main Street Seep
Room 100 Wx
Northampton, MA 01060 T lane Wiz=
phone 413 - 587 -1240 Fax 413 - 587 -1272 i�.3 >as $n Afr
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION ►►a,i ((11a
p , This sVstlonto oe ttpleted by office
1.1 Property Address: Z i tt K�
41.0 / MA c
f 0 Z Map Lot _ Unit
Zoee OvertayDistrict
.Elm St District CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
7 7
Name (Print) / ' Current Mailing Addr7
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION!COSTSI
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ti7 •
C3 (a) Fee
C3 c� .i
J
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
This Section ForOffciai Use Orify
Date
Building Permit Number: Issued:
Signature:
Building Commissionedinspector of Buildings- Date
File # BP- 2010 -0655
APPLICANT /CONTACT PERSON WATLING SHERYL V & RICHARD H WATLING
ADDRESS /PHONE 129 RIVERBANK RD NORTHAMPTON (413) 320 -7442 ()
PROPERTY LOCATION 129 RIVERBANK RD
MAP 25 PARCEL 026 001 ZONE SC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid f
Buildin_ Permit Filled out V _ -
Fee Paid •
Typeof Construction:_Renovate Kitchen/Bath
New Construction
Non Structural interior renovations
Addition to Existing,
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
1NF9RMATION PRESENTED:
L 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
/4 9 / IA
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.
a
129 RIVERBANK. RD BP -2010 -0655
GIS #: COMMONWEALTH OF MASSACHUSETTS
viap:Block: 25 026 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Non structural interior renovations BUILDING PERMIT
Permit # BP- 2010 -0655
Project # JS- 2009 - 001188
Est. Cost: $8000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 5314.32 Owner: WATLING SHERYL V & RICHARD H WATLING
Zoning: SC(100)/ Applicant: WATLING SHERYL V & RICHARD H WATLING
AT: 129 RIVERBANK RD
Applicant Address: Phone: Insurance:
1 29 RIVERBANK RD (413) 320 -7442 0
NORTHAMPTONMA01060 ISSUED ON:1 /11/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: Renovate Kitchen /Bath
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 1/11/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo