24A-133 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
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
°, 600 Washington Street
Boston, MA 02111
���+� www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /ElectricianslPIumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): D .P . Carney Construction, Inc
Address: 34 Horseshoe Circle , -
City /State/Zip: Ware, MA 01082 - Phone. #: 413 - 967 -7124
•
Are you an employer? Check the appropriate box: - Type of project (required): i'
1. I am a employer with 10 4 . ❑
. I am a general contractor and I 6. ❑New construction
-
employees (full and/or part-time).* have hired the sub- contractors
listed on the attached sheet. 7. ❑ Remodeling
2. ❑ I am a sole proprietor or partner-
ship anri have . no employees These sub - contractors have. 8. ❑ Demolition
wort ng for me in any capacity. employees andhave workers'
[No workers' comp. insurance _. comp..inspr:inre� #_. 9. Q Building addition
required] 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have xercised their 11.0 Plumbing repairs 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. ❑ Other
comp. insurance required }.
*Any applicant that checks box #1 must also fill out the section below showing theirworkers' compensation policy information_
t Homeowners who submit this affidavit indicating they are doing all work and than 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 employers, 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: Char t i s Company
Policy # or Self -ins. Lic. #: WC 0 0 9 9 3 0 6 2 4 Expiration Date: 11 / 15 / 12
7ob Site Address: 397 Prospect Street City /State/z Northampton, MA 01060
Attach a copy of the workers' compensation policy declaration page•(showiug the policy number and expiration date).
Failure to secure coverage, as required under.Section`25A ofMGL'c. 152 can lead to the iiiiposition of criminal penalties of a
fine up to $1500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a frnP
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
- -. _
rnvestizations of the DIA for insurance coverane verific fic ,
I do hereby certify under the pains enrt'i s of perjury that the information provided_abov.e is true aril correct. __ __ __
Sigttature: --
ha te:
Phone #: 4 67 -7124'
Ofjirirrl use only. Do not write in this area, to be completed by city or town offciaL
•
City or Town: • . Permiit/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 #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not �+(1 Applicable 0
c
Name of License Holder : 1� I ��-�� 'Q 1 1� 1 (?
License Number
34 . ' she C 1octr -� m 0o g I g I X13
ddress . Expiration Date
,4 4L3 3- 103
ignature �s� ephone
9. Registered Home Improvement Contractor, `F L;L # _,,i, _ I N , a ,, . ., Not Applicable ❑
1) „ P . Cctrn e C lon
corn an Name Registration Number
r f'_ ` L11 Ia 1aD19
Address �1 4 Expirat on Da e
Wart K � • OtQ a r�^ Telephone ` l ',a-4
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 No No ❑
11. - Home Owner.. Exen%ption
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
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 r'71,
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing 5a
Or Doors ❑
Accessory Bldg. ❑ Demolition El New Signs [1J] Decks [CI Siding [O] Other [0]
Brie Description of Proposed R � (/ ( ( d i ^ (A t 0 1----(a/ ro C/i . 7-70c) •
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll - Sheet
G '. If New C 6iise eiiirei adtltt ' i � ' a / iil.to =< 'existlnc(�firils iii-E 6ete, 1 the folt6Wina:
a. Use of building : One Family /1 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 WNEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Mark( 1LL r A c) e ,nct (, .1 +- , as Owner of the subject
property
hereby authorize ii`t' 4 Ca-`11 et4 CenS4TIAC8 an ,....3-n c
to act on m behalf, in all matters elative to t authorized by this building permit application.
Signature . Owner Date
I, 10 , ! ' C' osn.e Gras\Turt (L.Iban in Cow , as Owner• uthorized
Agent hereby declare that the sta ements and information or'the foregoing application are true and accura ceto the best of m - _ -dge
and belief.
Signed under the pains and penalties of perjury.
OortnfN Cacoe
Print Name
• tgnatur: of Owne • gent c Date
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 r+,, ),,.
_
Lot Size _ _ , ._.....__._ _ .
:;
Frontage L. d } _. ' .,__._. _. _.__ __._.
Setbacks Front _I L
1 ,
Side L ' .___ R =— L:I J R:' ,____
E I
Rear L _..1 i a
Building Height ( 11
Bldg. Square Footage r E r } %"-1 i
Open Space Footage W
(Lot area minus bldg &paved ` a ,
parking)
# of Parking Spaces = ' ---
Fill: 1 . I „��.�...�a�
(volume & Location) - -•_- -
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO O 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 z Page i and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW *) YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
.............................. ...............................
Needs to be obtained Obtained 0 , Date Issued
C. Do any signs exist on the property? YES 0 NO trio
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO l
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, gradin• excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO ►�
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
t17eartrne use only
City of Northampton �t ' )t-''' 4I��'
a Building Department Gtl •, D th erhit�
212 Main Str 5 w a labi
f
AUG — 2012 Room 100 a r c r r '
i Northampton, MA 01060 'P �` a e rrs vim
i o B , EC 413- 587 - 124 0 Fax 413- 587 -1272 P1�ti tf ��� ,, ,
L..
NORTHAM iA010E0 7 ^° - b �^- ,
_�r e p Ctrs a
e ',
APPLICATION TO CONSTRUCT, ALTER, REPAIR, R O DEMOLIS A ONE OR TWO FAM DW ELLING
SECTION 1 - SITE INFORMATION _
1.1 Pro
This section to be compl by offi
4'a + Sli - f Map °Lot Unit
00 a-- cum-
f It' J ' I 0 101, O oZne °� CB District
Over Dis trict
Elm S L District
SECTION 2 - P ROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
qr Ass et�a 1.1...
39 1 fic c
4- � NOr aI n, (YID .
Name (Print)
Telephone
Curren, cling dd ss: n 0 Ld
Signature
2.2 Authorized Agent:
r lit C A rnP PCC. � �f �5 G I WCkka i 1 r1.
me (Print) Q (i ' Curre Mail ing Addres
t. _, (;) ry -- .-- ,
Sign ature Telephone
SECTION 3 - ESTIM CONS ION COSTS C.l. l•-'L-A---'
Item Estimated Cost (Dollars) to be Offic Use Only
completed by permit applicant
1. Building R 1 0 (a) Building Permit Fee ) I
2. Electrical 1 ( b ) Estimated tal of
Bu
Construction T o fro m Cost (6)
3. Plumbing ilding Permit Fee
4. Mechanical (HVAC)
5. Fire Protection _
CI- �� C heck Number r
6. Total= (1 +2 +3 +4 +5) 1) i� —l• / 5 W .J
This Section For Official Use O nI y
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Building s Date
397 PROSPECT ST BP- 2013 -0142
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A -133 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- 2013 -0142
Project # JS- 2013- 000232
Est. Cost: $12759.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: D P CARNEY INC 99798
Lot Size(sq. ft.): 22694.76 Owner: WILBUR C KEITH & SARAH WILBUR C/O MARK E ARSENAULT
Zoning: URA(100)/ Applicant: D P CARNEY INC
AT: 397 PROSPECT ST
Applicant Address: Phone: Insurance:
34 HORSE SHOE CIRCLE (413) 543 -4803 WC
WAREMA01082 ISSUED ON:8/7/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE FLAT 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 8/7/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner