29-016 (6) 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, 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 backed!),
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
jermits 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
1 7.
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. The Commonwealth of Massachusetts
Department of Industricd Aecidents
Office of Ini
SEES=.7 600 Washington Street
Boston, JIM 02111 .
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www.mass uov/dia •
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-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/PI
Applicant Information • Please Print Legiblv
Name (BusinesS/Organization/Indivirinat): Wy"j4/1 ?)1A , •,•,•
. ..,,,..,..
, , , Li
- . Address: eAp 9 tO e- e,/i is ; • • •
1 7 e 07 2
City/State/Zip: ,A,u,t-e5O" 1:4, r M4 Phone.#: q /3 7,0 --le ti
Are you an employer? Check the appropriatebox: ' Type of project (required): 11"
1.0 I am a employer with 4. 0 I am a general contractor and I
6. New construction
have hired the sub-contractors
employees (full and/or part-time).
listed on the:attached sheet 7. Remodeling
2. I am a sole proprietor or partner-
These sub-contrac-tors have
ship and have rip, employees .8. 0 Demolition
working for me in any capacity. emiloyees-andhave worke rs' . „.--,. , - ..- . -; •
9: LaThilidingnildition
[No workers' comp. insurance
required.] 5. 0 We are a corporation and its 10.0E1=:if* repairs or additions
3.0 I am a homeowner dOing all worlc officers haVe4xereised their . 11.E] Pluinbing repairs or additions .
myself [No workers' corop. • 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
• . • con:qi. insurance require-d.j. . II • • ' I .
*Any applicant that checks box famust also fill out the section belowshowing their compensation policy infonnalien-
f Homeownern who submit tbii affidaVitincficating they are doing all work and then hire outside contraetors must submit anew affidavit indicating such_ ..
1 p:curacy= that rbiq-lt this box must attached an additional sheet showing the name of the subconttactors and s (Mx wietber•or notthose-ettities have •
employees 'lithe sub-conmactorshaie employe, they must provide their wOricers' comp policy number.
I am an employer that is providing workers' compensation insurance for my einplOyees. Below is the polkyan.d job site
information.
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. . • .
In.surance Company Name: .
. • • .
Policy # or Self-ins. Lic. #: , - . Expiration Date: - • :
- .
Iob Site Address: • ' City/State/Zip:'. - ' . • , ' , _ - ..
Attach a copy of the yvorkere compensation policy declaration page (showing the policy number and date).
_
Failure to secure coverage as reciiired Ini 152 can ]eid the iinPoiltioii Of Ciiniinal iienalties of a
tine up to 51,500.00 and/or one-year iinplisonment, as well as civil penalties in the form of a STOP WORK-ORDER and a fine
°flip to $250 00 a day against the violator Be advxsed'that a copy Of this statement may be fOrWarded.tO the.0t6OCiof
'Eiregit Venfication. . . • _-_. , .., :',...-... --...,,..,_:....,_,.
fhere..b_yCir.ir under the p • and penalizes ofperjury that the informatitynprOvided:tib ov.elEthre.azia...6;riprt
• •
Signatrre: ,' ' 444 1 ,e 4, Y d/-4, . . Date;
Phone i: . '1 4,T ---ia W _ .. ' :.:. ''. ' -. ' . _ • - • .
. - Official use only. Do not write in this trrea, to be completed by city Or toWnOffichil
City or Town:
Perniit/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 #:.
i .
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : i ' c ' L c1 J C C� 6 0 n
License Number
( 404 LL 9 C R SLR Mt 2 z // z
Address 0 t, Expiration Da e
Signature le one
9. Re istered Home:lnip ovetnent Contractor . .,. _ .. , Not Applicable ❑
?cp. 7 R A,el /27 6.06
Company Name Registration Number
Address / 1 D� Q 1 /� �/�J did -7 2 Expira ion DaTT {e
VCS `7 `4 i°�/1 U,64.k 1 fi!4 Telephone? / � j 25
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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....e No ❑
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 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
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 [] Replacement Windows Alteration(s) J Roofing L
Or Doors D
Accessory Bldg. �.. Demolition ❑ New Signs [D] Decks [E] Siding [D] Other [0]
Brief Description of Propose /3 X/
Work: C iT t` ✓\ 4Cr tr'G J''
Alteration of existing bedroom Yes ►y No Adding new bedroom Yes ( 4 No
Attached Narrative- Renovating unfinished basement Yes No
Plans Attache(Rol J - Sheet
sa If,New house. ��d -.nr xddi'fion.to'ez�sti u: i °ci' sma, . h�l le>�e the.fo[I"o inc :
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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 'C. -/ ' (c _ , as Owner of the subject
property
hereb authorize CL-h -
to - - • my behalf, in all rn ers elative to work a orized by this building permit ap lication
�.. %rJ / c� ' 2 j / s-o /1
sr
S a u :6 Owner Date
1, _ ; ?9' -Vec' -- L / , as Owner thor�ize
Agent hereby ddclare that the stdtements and information on the foregoing application are true and accurate, to the best of edge
and belief.
Signed under the pains and penalties of perjury.
Lr 4 — •
Print Name
Signature of Owner /'` < -nt ' , Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplet information 71
Existing Proposed Required by Zoning
This column to be filled in by ,
Building Department r !API
Lot Size - 1 ! s # . _r
,t
Frontage
Setbacks Front I
Side L.... R.I, __- L.i . __..i R: L_ F
Rear s
Building Height r ' : ri
Sao
'' 7
Bldg. Square Footage r i • l% i f [ d � i i
Open Space Footage % ----'
(Lot area minus bldg & paved .„ _ m �a
parking)
r 1
# of Parking Spaces
Fill:
1
(volume & Location) £
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book ' i Page; ? and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 4 50 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
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 Q
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 Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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EIVED City of Northampton
Building Department Ou • =D 1t z 4
l 2 Main Street
MAI a • ya
L Room 100 : •` 4•
orthampton, MA 01060
DEPT. of BUu ,i11; - 41 :- 587 -1240 Fax 413- 587 -1272
• Vi , 0 1
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: µ
g :Map Lot Unit
1v-c Zone Overlay tr
St District CB Pis Dist rict
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
JII1 at r Cm 3 l'o r ,.., �>r- r
Nam- t) Current MaT g A dress:
Telephone ) C3
Signature / 5— / 0
2.2 Authorized Agent:
f
W di "R J.) - / 006 6- 81t � 1114 CI 6 7,
Name (Print) ✓ 7� "�r � ,J/ Current Mailing Address:
/.„.yZ C 1 flit . ��7 (c-( /�'
Signatu 7 Telephone
n -1
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building eyo -� (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
Check Number
(.+� D
6. Total = (1 + Z + 3 + 4 + 5) 8 ( / p
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0966
APPLICANT /CONTACT PERSON RYAN REGAN -LADD
ADDRESS/PHONE P 0 BOX 59 SHUTESBURY (413) 259 -1149
PROPERTY LOCATION 32 HICKORY DR
MAP 29 PARCEL 016 001 ZONE URA(100) //WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out � 5ff 460
Fee Paid
Tvpeof Construction: CONSTRUCT 13 X 13 SCREEN PORCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 060508
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORyATION PRESENTED:
' pproved 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
-- c S72-67 t
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.
32 HICKORY DR BP-2011-0966
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 016 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit # BP-2011-0966
Project # JS- 2011- 001584
Est. Cost: $21000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RYAN REGAN -LADD 060508
Lot Size(sq. ft.): 14592.60 Owner: FEICK ELIZABETH C
Zoning: URA(100) //WSP Applicant: RYAN REGAN -LADD
AT: 32 HICKORY DR
Applicant Address: Phone: Insurance:
P (413) 259 -1149
SHUTESBURYMA01072- 0059ISSUED ON:5/26/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: CONSTRUCT 13 X 13 SCREEN PORCH
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 5/26/2011 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner