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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
regulations Th_. a inspection process r quir 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 sued,_and_ 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.
Address of work
location
The Commonwealth of Massachusetts
Department of Industrial Accidents
=W ( Office of Investigations •
fg ='- a 600 Washington Street
Boston, MA 02111
'� www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumb.ers
Applicant Information / /� Please Print Legibly
Name ( Business /Organization/Individual) / D/M 2 L/lrtl G8ae2IL GQ/7T 4 /��"OR—
Address: ?O. Sort'
City /State / Zip: (, t /- ?� J`� . ,./p/2.._ Phone #: 2 i/3-297-L5,41/ 5
Are you an employer? Check the appropriate box: Type of project (required): /
1. (_v1 I am a employer with ) 4.. fl I am a general contractor and I 6. 0 Ne 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. odeling
ship and have. no P^iloyees These sub - contractors have. 8. ❑ Demolition
working for me in any employees and have workers'
Y c aP aci ty. 9. 0 Building addition
ss n•anc
[No workers comp. insurance repairs required.] 5. Cl We are a corporation and its 10. ❑ Electrical ep irs or additions
3. I- am- a- herneo-wner- -d g -all wort o e s
r_aav �t,ezciscd_ it _ 11.0- Plumbing repairs 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 requited.
*My applicant that checks box #I must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affrdavit.indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
=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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: /i 6 ,j25` t ' // /!/T l/GA �/ ?�.
Policy # or Self -ins. Lic. #: ' / Expiration Date: - A 2/ 0 10/3
Job Site Address //9 /V4/1/A4 (2d , /`O/L ew6G° City /State/Zip • t)/0,4 (j
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 criminal 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 afi
of up to $250.00 a day against the violator: Tie advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby* certify nder the pains and pen = • perjury that the information provided ` uean _comer _ __
re ill!i // � 1.? Date. ;/
viyArAir
Phone #: /3 - gig 7 ,_ .5 -74
Official use only. Do not write in this area, to be completed by city or town ojciaL
City or Town: Permit/License #_
Issuihity (cr one):
I. Board ng Aut of Health or 2i . B cle lding Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector __ _
6.
6. Other
Contact Person: Phone #:
I .
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ 11
Name of License Holder : / ° t 2 d/ /q k} ( $ o?o2d'/
License umber
?0, .tor 491 ao_pieit vi //r . 4/o/2 /? - S- c2913
Address Expiration Date
` -297 -S /6 G/
Signature Telephone
9. Registered. Home° Improvemnent:Contradtor ..;., ... ... , .., ., Not Applicable ❑
�� ,7v.Cpry 6eik.iaai, (lL> $ /2 09foo
Company Name Registration Number
E7,r 21
Addr ss / Expiration Date
C b gfeii ht /d �/l• 0 Telephone 1 //3 - 297- gq
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 build' g permit.
Signed Affidavit Attached Yes No ❑
The_current_ exemption for "homeowners" was extended to include Owner 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 1083.5.1.
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 referencVto 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
o amp on •refinance , _` .„ • i s-Gencr-alL-aays:Annotated. •
Homeowner Signature
. • 'i
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [p] Other [p]
Brief Description of ProPposed _J 'i/ .✓9w
Work: 8eMOdei le /14 r A/ 6 *Wvef" 'Veal; vi of w4sh,'4 A 'tye.. i.v
✓ r /&pots- 4 w -L
Alteration of existing bedroom Yes No Adding new bedroom Yes No / Movie iaih er
Attached Narrative Renovating unfinished basement Yes ../ No
Plans Attached Roll - Sheet
I;a_ if.. Nevu house'',and or :addition.to'exitinq'houshiq; complete the fo[Iouving:
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 C ®MPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERM
1, • ' , , as Owner of the subject
pro
hereby a' • rize / i i '
, 4
"
to . ' in my behalf, in -, m- ers r- - a to work aut orized by this building iermit application.
WM. dad 1. _... ' aa.O / _
Signature of Own -a(orti
L
/ vin A o, 6
I / 4e/7 (fin.42A0/ , as Owner /Authorized
Agent hereby declare that the statements and information on t (fin application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
- 7O41 "Dvh4t
Print Name
' ~Al- , r/
liti
Signatu of Owner/Agent D
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 Ct
Lot Size
Frontage
Setbacks Front
Side L. ,_._ _. R. _,_ ,_ L:,_
Rear ...
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved m,
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES
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 and /or Document # F
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 0 Obtained
, Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe -size, type and location:
j D: ie t�iere any proposed aii "n'ges to or a itions o signs inten�ed-for the property ? YES 0 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.
� - � P = -� ,� r,mk e s e on - i 0
r City of Northampton stafus p f Perm U
Building Department Cii tifi w a i RO s it s
212 Main Street SewSefrt3Auariaf r[y ; � �
A,
6 21112 1 Room 100 1/lla en # tI Avaria ttt (' S t q --
Northampton, MA 01060 T a sh ,
pEiT. of suiLa!au iNsPecrroirs ph ne 413- 587 -1240 Fax 413- 587 -1272 Pi�pf/ ° to � an � 0
NORTHAMPTON, MA 01060 ' e -
Other Speef �` p 20
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: .e
/h2. We0AA1 / ; .A �� Map Lot Unit
,
CAOR'vC „`4. O/dbo Zone Overlay District
Elm St? District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
r
�- !_ard ,-n --- - -- -- _ _ b/2 .e. xn - ae eoize /14, ev000
Na ex Print) ` Current Mailing Address:
Si nature T elephone G i ii 3 — 2-3 —,30 .2,
9
2. orized Ag
7 D O,C aW ? a, / 014 a e‘.5 iriCeb 4. D /v/Z
Name (Print) Current Mailing Address:
� _i i — - , . til- — 2", 7 --- (57 6
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION-COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
3y , , .
2. Electrical (b) Estimated Total Cost of
b o
Soon Construction from (6)
3. Plumbing acs Buildi Permit Fee
ZZOa ,3
4. Mechanical (HVAC)
5. Fire Protection �/�
6. Total 7T {1 +2+3 +4 +5) 3/ p
f3S, °c) Check Number r j / /
This Section. For Official Use Only
Building Permit Number. Issued:
i '�_ - /
Si nature: �,, � ,. A
9
Building-Commissioner/Inspector of Buildings Date
112 NORTH MAIN ST BP- 2013 -0105
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C - 266 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- 2013 -0105
Project # JS- 2013- 000167
Est. Cost: $39538.00
Fee: $237.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THOMAS DOLAN 039281
Lot Size(sq. ft.): 5052.96 Owner: GIARDINA ANTHONY & EILEEN
Zoning: URB(100)/ Applicant: THOMAS DOLAN
AT: 112 NORTH MAIN ST
Applicant Address: Phone: Insurance:
P 0 BOX 297 (413) 585 -0612 () Workers Compensation
CHESTERFIELDMA01012 ISSUED ON: 7/27/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN,CABINETS,NEW
WINDOW,RENO 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 7/27/2012 0:00:00 $237.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner