31A-208 (2) 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
Permits 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
- ,
— •
• - -
The Commonwealth of Massachusetts
. • Department of Industrial Accidents
Office of Investigations
m.orni . ..■• a., 600 Washington Street
Boston, MA 02111
• , www.mass.gov/dia •
- Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
...-- .....,
Name (Business/Organization/Individni 1 CX; 4 -,,,,,e , (-;,.,.„ e -,/,, A.- fr, ,' e G.
• 7 Address: e - 4-7.,..* 4.1: 7/ e7'h c r r -
• A , e' A el.f.
City/State/Zip/A4-77 MA - , --d - — Phone.#: £f/1 2% 'e 7f
Are you an employer? Check the appropriate box: Type of project (required): /
• 1. EJ I am a employer with 4. 0 I am a general contractor and I • 6. 0 N,w construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet 7. r",
2. 0 I am a sole proprietor or partner-
• ship anti have no e.iloyees These sub-contractors have. 8• 0 Demolirion •
employees and have workers'
working for me m any capacity. 9. ir3 BuildiUg additiOn
I -
[No workers' comp. insurance ..... --, 3 --i 2 surance- -- - '
10. Electrical repairs or adclitions
required.] . 5. 1 are a corporation and its 0
3. 0 I am a homeowner doing all work officers havexercised their
.i. 11.0 Plumbing rep 'airs or additions
myself [No workers' comp. 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
comp. insurance required.] "
*Any applicant 1hat checks box #1 must also fill out the section below showing their workers' compensation policy information.
• t Homeowners who submit this afridait indicating they an doing all work and then hire outside contractors must submit a new affidavit indicatbig such
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whetheror not those entities have
employees. If the sub-contractorshave employees, they must provide their workers comp policy number.
l'am an employer that is providing g workers' c ompensation insurance for my employees- Below is die Polley andjob site
information. .
• .
Insurance Com • pany Name: • .
• -
Policy # or Self-ins. Lic. #: • Expiration Date: -
Job Site Address: City/Sti.fe/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 Sectiiin ofMGL c. 152 can lead to the imposition of ciiiiiin41 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 $250 00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Thrfeitions of thi DIA for insurance coverage Verification.
I do hereby certify u the pains am i penalties °fp erjmyiltat the information provillidizbove_isirue_azid_correct._______ _ • Si tore: 2 Dat: ,-. Z---//
Phone 0: Zi/ 1' r.-Vi 71C - • •
Official use only Do not write in this area, to be completed by city or town officiol
• City or Town: • .. Permit/license # • •
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical, 7.,nspector 5. Plumbing Inspector
6. Other f. . • Contact Person: Phone #:
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
/1
Name of License Holder : C. 67 ° t +► '
License Number
r
Address Expiration Date
Signature Telephone
Aetiistiiid tt#ne:= trriti' `i eitiiebtti rt radtor' 'x a xe .; _ .. Not Applicable ❑
� slG Co./.i'Tilceict % //
Company Name Registration Number
� A '7'...4=6-
� �-il ‘j; /1 ,V4 %jam �' /f' •Sy //4.-
Address '/ Expiration Date
Telephone L r I- fi !mo d
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 L•]' No ❑
umekkovvinerxempuon
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 0 Replacement Windows Alteration(s) Roofing ED
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding [O] Other [0]
Work: Description of Proposed / Jet er . C /J4
w � 1, � r f el., / se � �' �--► P .'J� `Z a v 1� �f
Alteration of existing bedroom Yes i-- N o Adding new bedroom Yes .••
Attached Narrative Renovating unfinished basement Yes � ' . No
Plans Attached Roll - Sheet
Wit house anncl' r a C • 4to liIstina h0 ll
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
I, Ch tl ^ 1 Vi e_ Al Ckst , as Owner of the subject
property �" r
hereby a • • .ze 1 ( IfN C-bl\-
to act • m ;behalf, in all matte r- a ive to work authorized by this building permit application.
Signature of Own-'. Date
1, j4ve e6, -,, ,n 1° _ , as Owner uthprized
gen h declare that the statements and information on the foregoing application are true and accurate, to the best o y knowledge
elief.
Signed under the pains and penalties of perjury.
A ,e. � CC: e -,, .,4 r
Print Name 7
Signature of ner /Agent Date
//�
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required b Zoning
This column be filled itihy
Building D artmaht
Lot Size i J t i _
Frontage 1 1
::
Setbacks Front '
Side L: R: L: R: a i
Rear
Building Height i I
Bldg. Square Footage I t I 1% { i r i
i s
Open Space Footage %
(Lot area minus bldg &paved ? [1 7_1
parking)
# of Parking Spaces ! ~- • " I_.
Fill: i _
(volume & Location) i 1
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 Q YES 0
IF YES: enter Book . Pagel and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , 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 0 NO 0
IF YES, describe size, type and location:
I
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.
- g a
{T f .:.,. t":Ne o City of Northampton -E . '
: uilding Department - -_ . .s
2 2 1.0 212 Main Street
VOW Room 100
• • •� ampton, MA 01060 � � � � ' -'
�����
• 3- 587 -1240 Fax 413 - 587 -1272
111 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
9 (, ; /fr % , AA/f. ;Map Lot " " Unit
:7 Zone" ; Overlay "District
Elni St District . CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: // / • p� ` ,p►� /
• "L- 7'` Cf r f -T. 4 / Ac-e. cite F 1� 4 'S 4' /' �l•'
Name • Current Mailing Address:
,ItglIv 1 Telephone
Signature
2.2 Authorized A. ent: / J
Name (Prin Current Mailing Ad ss:
Sign., Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building � a� (a) Building Permit Fee
2. Electrical 'Jr-ere (b) Estimated Total Cost of
Construction from (6)
3. Plumbing 7 a Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) / g > J" d Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0748'
APPLICANT /CONTACT PERSON DAVID CHICOINE
ADDRESS /PHONE 16 EDGE HILL PLACE AMHERST (413) 246 -7536
PROPERTY LOCATION 8 WASHINGTON AVE
MAP 31A PARCEL 208 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 0 9/
Typeof Construction: CONSTRUCT LAUNDRY ROOM IN CLOSET
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 061582
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF MATION PRESENTED:
Approved 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 Peimit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
Demolition Delay
//:"--A".22 /
Signature of Building Official Date
g g
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.
8 WASHINGTON AVE BP -2011 -0748
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 208 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2011 -0748
Project # JS- 2011- 001239
Est. Cost: $13500.00
Fee: $81.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID CHICOINE 061582
Lot Size(sq. ft.): 10497.96 Owner: ARCESE ERIC G & CHRISTINE S
Zoning: URB(100)/ Applicant: DAVID CHICOINE
AT: 8 WASHINGTON AVE
Applicant Address: Phone: Insurance:
16 EDGE HILL PLACE (413) 246 - 7536
AM H E RSTMA01002 ISSUED ON :3/25/2011 0:00:00
TO PERFORM THE FOLLOWING WORK :CONSTRUCT LAUNDRY ROOM IN CLOSET
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: I Rough: // f i J House # Foundation:
Driveway Final:
Final: Final:
Rough Frame: (` p j i
4 K 1 I t r 1)
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation: iec 4- , 1 ` C' viP
Final: Smoke: Final: 01< 6*-- /1 C
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REG
Certificate of Occupan a ture: dir# 16.aze "A. i ".t.'
p
FeeType: Date Amount:
Building 3/25/2011 0:00:00 $81.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner