36-061 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
j ermits 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
Date
Address of work
location
,
. .,
The Commonwealth opfassachusetts
==,27------ Department of Industrial Aecidents
Office of Investiga .
t FEL411__—=
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit Duilders/Cont
Applicant Information , Please Print Legibly ::
k ,
--
Name (BusineseOrganizationfIndividinD: lEcke 6;4)7 ,0 ( (
Address: .
•
r
•
City/State/Zip: Ak .C 4 "lib N riA fr O "" Phone .#: 6 4 --4
Are u an employer? Check the appropriate box: Type of project (required): 1
2; 7
1. I am a employer with 2 .---4
4. 0 I am a general contractor and I
6. L j New construction
have hired the sub-contractors
employees (full ancVor part-time).*
listed on the attached sheet 7. 0 Remodeling
2.0 I am a sole proprietor or partner-
ship and have no .employees These sub-contractors have . 8. 0 Demolition
working for me in any capacity. employees and have workers'
9 13 Building ilditiOn
_ comp.insmance.t:
[No workers' comp: i repairs or additions
nsurance-
10.0 Electrical
require] , 5. 0 We are a corporation and its
3. 0 I am a homeowner doing all work officers havexercised their 11.0 Phunbing 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. o workers' 13,0 Other
con p. insurance reqUired.J. . .
*Any applicant that checks box #1 must also fill out the section beloW showing their compensation policy infomettion.
1. Homeownera who submit this afrada;tit indicating they are doing all work and then hire outside contractors must submiia new affidavit indicating such.
:Contract om that check this box must attached an additional sheet showing the name of the subcontractors and stain whether or not those entities have
employees lithe sub-contractors bait employees they must provide their workers comp. policy number..
lam an employer that & providing workers' Compensation insurance for my implbyees. Below is the policy and job site
information.
7 ..–
Insurance Company Name: 4 i 1 5 50- ry ,.. ill 0•0, I / 13 1 , 6 Cb
_ .... ,
Policy # or Self-ins. Lic. #: IC ::)‘ - 3 /■) (9s4 i 7 f - C 21 ° Expiration Date: - (16 -7•5 es ) -1. _ ." '. --
f 0/062.
c y o
Job Site Address: 1 9 0 ) U 9 1 ji City/State/Zip:', t. C 4)6 i
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
_ .
Failure to secure coverage as required under Seetiiiii 152 can read to the itiipOsitiOn Of crininal penalties of a
fine up to S1,500.00 ancVor 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
ThfireitOns of th Ciiiiiii.i " • " -----4 7 4---- -------,---- ----- _
.,......._..._ ._ ... .._....... .. _ ... ._,
_ Ito hereby_perti y under the pains.and penalties ofpedury that the inforntationpmvided_above..ii.tnie_and_Correm. _.
Signature : -- --- ; '-- Dat : 1-1, c; 0 1 1
t
Phone it: 51 4-- i / 4 / - . - -
• • Official use only. Do not write in this area, to be completed by city or toivrzUkzciaL
City or Tovvn: .- 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 , 1" .
Contact Person: Phone #:
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �1 Not Applicable ❑
yr/ --��
Name of License Holder : ^ �' :� / !i^ " p'`Ib7
E ,e) #6) AA-7- License Number
Address Expiration Date
d . 00 - l\Am T6i r 4- 044. 0) c?-7' lsf
Signature Telephone
.2l eiiisteretl tt e 1 iiiii menitCotitra torN . %Qx F ' ` ". r , ..T Not Applicable ❑
p3� >2 d) ufr �da,f .� /6096 /
Company Name v Registration Number
Ad ess Expiration Date
/7®4 A hy B pi A 006° Telephone 6 9/L7
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affiday 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 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 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) D Royfing
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding NU( Other [0]
Brief of Proposed N id)/ 61 pi J S / J`
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
s �� c orpse: l t � cl' n tEaw�is# >ic fiocl is ccimpl le th fc l ng
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
1, Imo+ Z / /0 f CL , as Owner of the subject
property J ' /
hereby authorize ' GA)/es L_.
to a •my behalf in I matters relative to work authorized by this building permit application.
` Lc2.1
Signature .f Owner Date oe,
1, I3 L WR 9 , a r7Authorized
Agent hereby declare that the statements and informati on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
eA) ; w3 L it4
Print Nam -
Signature n56rrne77Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To lig'iiirlete Information
i.
Existing Proposed Requ' ed b5 Zoning
This co n to be filled in by
Buildin Department ., t
o — 1 i i ,
Lot Size L f
Frontage 1 1
Setbacks Front ` �" _1
Side L:` R:1 ? L : 1 R:= j
Rear = i
Building Height = 1. i
Bldg. Square Footage % 1 I
Open Space Footage % .
(Lot area minus bldg &paved 1 1 ..
parking)
# of Parking Spaces -°_-
".,.d.�•.., p,.».�� .. u,«.......w« t e«�......,� ,.•,- ,",�.... ".mow_
Fill: F
(volume & Location)
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:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
a
IF YES: enter Book 3 I Page 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 ,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 Q
a
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 Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
• • Northampton - e A 5
' ECEIVED : WI ng Department ` r
2 e Main Street
MAY 2 6 2014 Room 100 v . ,
N rth. mpton, MA 01060 ; . °
• 58 -1240 Fax 413- 587 -1272 `' a , ° _,
NORTHAMPTON MA 01080 ®= t
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: D �/ y ��
R 0 2 e 6 / p" Map Lot Unit
1 i'* / E A ) G 44 eV Uio zone ° overlay District
6 EInt St:; District '.` CB District
SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT
/,`
2.1 O ner of Record:
v7/
a Print
Na Current Mai est to c 6 in ✓8"
Signature fry.,, ,� Tele) Gam'f g
2.2 Authorized Agent: CC,, r
�QJ� 7 d er
/Z yr +S L 1'. '')0/ > (�,e , 1 4vC�/ 1 �t)J� a/
Name Print) Current Mailing ddress:
>: t514 "K7
gnature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 9f ci O (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
3o/ 5S
6. Total =(1+2+3+4 + 5) �,Lp C) ✓ Check N r
/
This Section For Official Use Only
Date
Building Permit Number: Issued
Signature:
Building Commissioner /Inspector of Buildings Date
•
1041 BURTS PIT RD BP- 2011 -0981
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 061 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit # BP- 2011 -0981
Project # JS- 2011- 001604
Est. Cost: $5200.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R SIDING 026846
Lot Size(sq. ft.): 13198.68 Owner: JIMENEZ REYNALDO & MILDRED
Zoning: URA(100) //WP/WSP II Applicant: B & R SIDING
AT: 1041 BURTS PIT RD
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586 -4167 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:5/27/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: IN STALL VINYL SIDING
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 5/27/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner