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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
1- •• - ' . r •rocess requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfll),
sonotube holes (before pour), a rough building inspection ( before work is
concealed), insulation ins p ection (if repaired) and a final building insp ection The
building department requires these inspections before the work is concealed, failure to
secu 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
_ per- its- rn conjunction _to_the_bu' _
inspections. Failure of the individual to h e that they their required
required can DELAY_ the project until such time as the proper permits and inspections are
made
(Home owner /resident's signature requesting exemption) understand the above.
I will call to schedule all required building inspections necessary for the building
issued to me. g p ermit
Address of work
location
The Commonwealth of Massachusetts
Department of Industrial Accidents
�� Office of Investigations •
k w _ 77 600 Washington Street
4 ' Boston, MA 02111
www.mass.govldia
- Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
.applicant Information Please Print Legibly
Name ( Business /Organization/Individual): 62/ -S7V' „,, l ..(C' r --
Address: o / //, 57— •
City /State/Zip: I 4,c( /1 ,3 /Q3 e- Phon #: ol `l 7 6 L
Are you an employer? Check the appropriate box: Type of project (required ): �
1. f I am a employer with. 4 - 0 I am a general contractor and I 6. ew construction
employees (full and/or part-time).* have hired the sub - contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
These sub-contractors have g
ship and have . Ioyees S. erto,z
ruon
workin g an for me in aci employees and have workers'
Y capacity. . -
[No workers' comp insurance comp._rnsurance.t 9. 0 Buddjng addition . _ -
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3- [i I am -aheme
ce _ have x ercise :11 -h — —1-1z umbingrepairs or additions
myself. [No workers' comp- right of exemption per MGL 12. [] Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
:Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy
g t hey are doing all work and then hire outside contractors must submit a new affidavit indicating such
information.
t Homeowners wha submit this affidavitmdicatin
$ 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. lithe sub - contractors have employees, they must provide their workers' comp - policy number.
Yam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: / l �/ /
/
Policy # ar Self -ins- Lic: #: 500 3 601 1 °Z G r� 3 Expiration Date: /
! ` e l s ,.., b G City /State /Zip:.
Job Site Address:: �d
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
srtion of crrn�inal penalties of a
Failure to secure coverage, as required under Section-25A ll pen ti es in the form. o�fa WORK OVER and a �e
fine up to $1 and/or one =year imprisonment,
of up to $250.00 a day against the violator " Ile advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA. for insurance coveraze verificadon.
I do y / hereby ce • under the pains and penalizes of perjury that the information provided - above zs_true.anLCOirect _ .__
T
II G �G Q � . —
_ : M
Phone #:
" Official use only. Do not wriife in this area, tta_bi completed ,y city or town official
Permit/License # -.a
_.. City. or Town:
Issuing Authority (circle one): . ector �. Plambin °- mss' ector
Board of Health 2._Building Department 3. CitylTow 4
n Clerk 4. Electrical I
6. Other -
Phone #•
Contact Person-
sECTtON 8 - CONSTRUCTION SERVICES
Not Ap plicable ❑
8.1 Licensed Construction Supervisor: eV 6 J 3
Name of License Holder : (d y �� 1tA `r
( Li c ense Number
E Date
Address /
Signature Telephone
Not Applicable ❑
s Registered: Horne. improvemei t. Contractor_ " 'M ` .4 / 53 ) _____ __--
'4'r� �'�-° 447 7t-4' 4-- Ex Re piration gistr
n Nunn
ber
Company Name � /� / J / Q
Address
Telephone dy��
_SETON 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GL. c. 152, § 25C(6)J
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure t0 rovide this affidavit will result
in the denial of the issuance of the building permit
p
Signed Affidavit Attached Yes
we
The_current_exemption for. "homeoxvners ",was extended to i .,
and to allow such homeowner to engage an individual for hire w er_occu p ied Dllina of
as supervisor. CMR 780 Sixth Edition Section 108.3.5.1. (1) or two
(2) a li cense, 2
() families
Definition of Homeowner: Person (s) who own a parcel of Iand on w hir sse rovided that the owner acts
is, or is intended to be, a one or two family dwelling, attached or detached stru.
structures. A person who constructs more than one home in a two -near perio es or intends to re at sidhe /e on which there
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Ty to such use and/ or e
res • onsible for all such work • erformed under the buildin ' • emit. onsi
rm dered f
As acting Construction Supervisor on the job site will be require
from time h omeowner.
or Y our presence J 9 thsh shall' be
completion of the work for which this permit is issued.
Alco bit advired that with roferenrwtn Chapter 157. (Workers' Compensat and Chapter 153 (Liabbfl .
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be pon
you hire - ta perf6 foryom uderthis permit- -- — — —
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code,
,. o amp on .1..1 ances, a e .n: ` o . .' . ,. .+ . ..:.. . -tts-General -L- aws Annotated.
Homeowner Signature
:CTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) s
Nw House ❑ Addition ❑ Replacement Windows Alteration(s) [J Roofing n
Or Doors D
:cessary Bldg. ❑ Demolition New Signs [0] Decks jEr Siding [01 Other [el]
ief Description of Pro h
posed [ v to t Q ec � / �g tC l2 G�► x�i �;�
ork: ( b C 's i v2�
eration of existing bedroom Yes ��o Adding new bedroom Yes . No
:ached Narrative . Renovating unfinished basement Yes
ins Attached Roll - Sheet
if New hoi7se arrd ar acltlltlor'E t� eirisEing ous na; complete the fallowing:
Use of building : One Family Two Family Other
Number of rooms in eat' fan -d unit Number of Bathrooms
"'ere a gara attached?
PrOpQSed Squate footage of new Construction. Dimensions
Unlbe[ Of Stories? Number of each ___ Fireplaces or Woodstoves _.___- ---- --
f. Method of heating?
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
No. Is constru within 100 yr. fioodptain _____Yes - - ---_No
h hype of construction Yes ___ -
i Is construction within 100 ft. of wetlands? __._ -__.
grade Yes No .
1. Depth of basement or cellar floor below finished g ____ ---
k Wili building conform to the building
a nd Zoning Te9ull City water Supply
City Sewer -- - COMPLETED WHEN
SepticYank 1ES FOR BUILDING PERMIT
OYVNER pUTNORI as Owner of the subject
SECTION AGENT ON TB .
owN�'�
e ..t- --cif, in all ma f relative to work authorized by this building permit application.
p �rop + ' / /a -- Date
sure of Owner t
'/ , as Owner/Authorized nowledge
ent hereby declare that the statements and information on the foregoing application are true and accu to the best of my
i belief.
ned under the pains and penalties of perjury.
4. { i'r 4- 1�3 - ��
Name �A ' —
- Date
ture of Owner /Agent
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 7 s
Setbacks Front P, 2
Side L: R...,,. L. R:
..&_
Building Height
Bldg. Square Footage _ %
Open Space Footage °
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special mit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW YES
IF YES, date issued: ::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW — YES 0
IF YES: enter Book Pagel and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ONT 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 —
IF YES, describe size, type and location:
D: - Are any proposed changes to or additions of stj iintended for the property ? YES 0 NO
IF YES, describe size, type and location:
E. WII the construction activity disturb {clearing, grading, excavatio 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.
- City of Northampton stt gP Pen *'�
Building Department CurJ�tpnveway Per>nIf
212 Main Street SewerlSe
\Room 100 w}ertwe� �al�
Ci \ 1ortha pton, MA 01060 Two S
ph -one413 581 1240 Fax 413 -587 -1272 F�tdttSte� laps �� � t
e( pectf g
At 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
r� �/L/ rd /9V C._ Map Lot Unit
/'� Zone Overlay District
EIm St District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: .
Name nt) Current ling Id s
1/1 Telephone, , t 3 r. e- 3 r
Signature 7
2.2 Authorized Agent: / �' � f /� ��� j
o/1.4S I / / d 7 (.)/41_ylrf
Name (Prin Current Mailing Address:
07 y -.S C 4 G (Ceti Ce F7
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION. COSTS.
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 7g0 ®te ( 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) ?" , Check Number
� �
This Section Frir l Use, On1
bate
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
•
File # BP- 2010 -0462
APPLICANT /CONTACT PERSON ROY OMASTA
ADDRESS /PHONE 21 North St HATFIELD (413) 247 -5666
PROPERTY LOCATION 78 HARRISON AVE
MAP 31A PARCEL 220 001 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 Q
Fee Paid 017° 40 g5
T Construction: REMOVE 10 X 26 PORCH DECK & REPLACE AFTER LANDSCAPING DONE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 006763
3 sets of Plans / Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN MCTION PRESENTED:
E A 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
-7/'>:"1---------. - I-- i...... i•
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.
PIS,.; v` BP- 2010 -0462
GIS #: COMMONWEALTH OF MASSACHUSETTS
31k4'42:11* 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 -0462
Project # JS- 2010 - 000637
Est. Cost: $7800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROY OMASTA 006763
Lot Size(sq. ft.): 7971 .48 Owner: DASHEF CAROLYN N
Zoning: URB(100)/ Applicant: ROY OMASTA
AT: 78 HARRISON AVE
Applicant Address: Phone: Insurance:
21 North St (413) 247 -5666 Workers Compensation
HATFIELDMA01038 ISSUED ON:11/2/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: REMOVE 10 X 26 PORCH DECK & REPLACE
AFTER LANDSCAPING DONE
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 11/2/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
1,78 fi : SOAI Ala BP- 2010 -0462
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 220 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 -0462
Project # JS- 2010 - 000637
Est. Cost: $7800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROY OMASTA 006763
Lot Size(sq. ft.): 7971.48 Owner: DASHEF CAROLYN N
Zoning: URB(100)/ Applicant: ROY OMASTA
AT: 78 HARRISON AVE
Applicant Address: Phone: Insurance:
21 North St (413) 247 -5666 Workers Compensation
HATFIELDMA01038 ISSUED ON :11/2/2009 0 :00 :00
TO PERFORM THE FOLLOWING WORK: REMOVE 10 X 26 PORCH DECK & REPLACE
AFTER LANDSCAPING DONE
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: 4---,(.240//0
A Rough Frame: OK r- L, s } s ` ll .,
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: Ok 7 7_ / cot,
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND RE . ),/ S. /":2
Certificate of Occupancy . ignature:
FeeType: Date lea d: Amount:
Building 11/2/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo