29-195 (10) 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 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
jiermits 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
I, 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.lifassachusetts
Department of Indu.strial ACcidents . , .
Office of Investigaiion:s • •
600 Washington Street
•:77.7:1.71-1= a Boston,1124 02111 .
, ---- - - ..
www.mass.gov/dia . • . -e. ,
::.•
-Workers' Compensation Insurance A.ffidavit: Bluilders/Contractors/Electricians/Plumbers '- •
....
..A.Tplicant Information • Please Print L - • bIv . :-..• -
, ,-----, .
:•'4
Name (Businesi/Orgoninitio . 1. .: .. ... . . ,,-.------.... 1 iv.-td
- ,
; -
* - Address: (R. . 0 ( 3X /
City/State/Zip: ,A44 0 I (5.5Phone.#: //3 3eF3--,.,7
La.p,d3 3
Are you an employer? Check the appropriatebox: • . •Type of project (required): 11'
1. 0 I am a . einployer with - 4•. 0 I am a general contractor and I , .. .
6. U New construction have hired the sub-contractors
exrplo. ym- . 1 ancVor part-tirtie).
listed on the attached sheet: 7. 0 •Remodeling
2....a Sole proprietor or partnea
d have no employees These sub-Contractors have .8. 0 Deniolition - .
. ship ali
working forme in any capacity. ( i I MAP-r-- 174. --4 4 - ,11 - 4- Y e 5vor - 9 ' Miatil*fiy
: OIL
[No workeas' comp. insurance
10.0 - Electrical repairs or additions
.- . 5. 0 We are a corporation and its
3.[::11 am a homeowner doing an worlc officers haVexer6 ;their 11.E1 Phunbing r as or additions .
myself [No workers CO mtp. . right Of exemption per MGL •
12 f repairs • . •
i nsurance requ]re t • . e. 152, §1(4)", and we have no .
employees: [No workers' 13.0 Other r •
s " • .
Any applicant-that checks box #1 also fill out the section below showing their compensation policy infortnatiCat.
t Homeowneen who subinit this affida:Tit.iturntating they are doing all watt and then hire outside contraitori must submit anew affidavit indicat*g such.
:contractors that check this box must attached an wirfitional sheet showing the name of the subcontractors and state whether-ornathose.entities have •
employees. lithe s /3-contractorsharie employeed, they must provide their wiiiceis comp. poRey number.
- i not an employer that is providing workers' compensation 'insurance for any einplOyees. Below is the policy andjob site
inforsnation.
. . .
.
- ' -
Insurance Company Name: • -
. . .
Policy # of Self-ins. Lic. #: . • Expiration Date:
. . ,• • . • • •
rob Site Address: ' : • • CxtyfStafelZrp
- Attach a copy of - the workers': compensation policy declaration page (showing the policy Unruh er and date).
• . • . . .
Failure to secure coverage ig reciiire BeCtirm 152 can lead to the iiiiiiiiiiiiiiii of -- `critniti iienitIlies of a
fine up to S1,500.00 and/or oneqear as well as civil penalties in the form of a STOP WOPX-OPDEIt. and a fine
of up tO S250.00 a day against the violator Be advisedthat a copy Of tbis statement may be forwarded to The Office Of
Itiv .iiiatliri. --- ---- : =777
rara ,:., , . —7 - .. ...:. •%-. olperjrayiltaithe infOrrnOnprovdab ......
signatur e: --,,---------7..--- ' '• . 7 : *--. .Iiii: -13 -. // - . • •
Phone #: 6 1 */ 3 1 97' -' • • - - ' ' - . • - • • • .
. - Official use only Do not write in this area, to be completed by city Or townofficiOI
. -
• 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 , .
Contact Person: Phone it:
• •
•
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. 1 1 Not Applicable ❑
Name of License Holder s ^� ') ✓ `�c"��-- �JU S
B `tx 1 / J /144 License Number
Address Expiration Date
��-- -- x / 3 217 l
Signature Telephone
9 . hears glom ` liciover iiiiii Goiiitraictar .,._ M 'SCit iVa M Not Applicable ❑
Com an Name Registration Number
6 DUX z''�S 4 1
Address
xpiration Date
47'4 �/ -U S ) 53 Telephone 4 3 i 1 ,/4J
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 •.
Signed Affidavit Attached Yes CT No ❑
11;t4 ohm: Avner
Exemotton
The current exemption for "homeowners" was extended to include Owner - occupied Dwellines 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 buildine 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) ❑ Roofing Ea.....---
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [O] Other [0]
Brief Description of Proposed
Work: amp 4.- 51► -.` ,) C. rU4-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
60iiiii'66ifielattrffilditittiAcriiiittedtidifitiiarciiiiiiirifillii tataiktia:
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
OWNE S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, n / SL.Q..31tCK, Y‘k \ n o-e ( as Owner of the subject
....),0,..,
property , .
hereby a horize 1 l Y 0 44R S° LvKc-�.
to act on behalf, in all matters relati to wok uthor'zed by this building permit appfcation.
Signature of Owner Date
I ,, i.... £ — j as Owner /Authorized
Agent hereby Clare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signe unde
Ana the pains and penalties of perjury.
n a . J L
-
Print Name
,l // .. /1
Signatu ffJwn n Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This col to befilled ;
BuildingDc:.artment #'" t
i
' Lot Size i 1 '.•
Frontage 1 ~ = i -----
Setbacks Front 9 i f
Side L:€ 1 R:1 i L:i R:i i,_
Rear
Building Height — j
Bldg. Square Footage - % - -" I
Open Space Footage % I
(Lot area minus bldg & paved i ___ I j i j EL 1—......._1
parking)
# of Parking Spaces
Fill:
(volume & Location) I
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 0
IF YES: enter Book ( Page I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ,Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: 1 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location: 1
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
i
e 3I
RECEIVE c
ty of Nort m "'k .0u
B ilding Department Y -
r i
A06 i Z zuu 12 Main Street
f
Room 100 w
o � ampton, MA 01060 i •
• ; 7 -1240 Fax 413 - 587 -1272 8 � = ''�
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
3 ff ()VQs /dot( . Map Lot Unt
Zone Overlay District
Elm St District '` CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Own r of Record: Q t O w "L
Own
Le c'U Yt; nne `3,g dJc lcsd lc. 9 r_ I :lc�vc Mil -
Name Print) - Current Mailing Address: I
o
C!" L ( Telephone ( _ q (3_ Si -0 2 2
Signature l J
2.2 Authorized Acie t:
,o J. L.LJ c..- V 0 13 6 x ) 1 L.12_/2‘?" s
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 lr" dc.) c.) (a) Building Permit Fee
i
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) / e ✓..) Check Number ✓
This Section For Official Use Only
Date
Building Permit Number: Issued
Signature:
Build Commissioner /Inspector of Buildings Date
- 4
38 OVERLOOK DR BP- 2012 -0170
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 -195 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2012 -0170
Project # JS- 2012 - 000255
Est. Cost: $10000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY J LUCE 100515
Lot Size(sq. ft.): 15463.80 Owner: KINNER HELEN H & NANCY LEILANI KINNER
Zoning: URA(100) / /WSP /WSP II Applicant: TIMOTHY J LUCE
AT: 38 OVERLOOK DR
Applicant Address: Phone: Insurance:
P 0 BOX 14 (413) 387 -9800
LEEDSMA01053 ISSUED ON:8/12/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & 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 8/12/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner