36-188 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, whidli include found ' s i aekili).
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 vvor�'can�e inspe`c'ted:. ._....�._ . .
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 s h time as the proper permits and inspections are
made
1, understand the above.
(Home owner /reside 's signature requesting exemption)
I w to schedule required -t i1ing mspe tib necessary for the building permit
issued to me.
Date
Address of work
location
t_ s, The Commonwealth of Massachusetts
---
---, -r Department of Industrial Accidents '
.� r Office bf Investigations
:.• - � A -" 5
600 Washington Street
Boston, MA 02111
t:` `"' www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /EIectricians/Plumber's
Applicant Information � Please Print Legibly •
Name ( Business /Organizarion/Individual): \' u4t ( .
��45 ( Jx't
Address:
to , X01 Li
Cit /State /Zip: \r}A& ` O, C.3 Phone #:V`) V--�--
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
mployees (full and/or part-time).* have hired the sub - contractors
I am a sole proprietor or partner- listed on the attached sheet. 7.0'Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
- — -- officers have exercised their ^_ _ 1111_0 Plumbing repairs or additions
3. n I am a homeowner-doing-all-work
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 #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit 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: _
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City /State /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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500:O0 and /oron yearimprisonment 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
Investi gations of the DIA for insurance coverage verification.
'` • r — he pains and penalties o era that the information rovi a byre is true and correct.
I doh p p of f p
Signature: �' Date: 1 t
Phone #: 4V "tic - ITO
Official use only. Do not write in this area, to be completed by city or town official
- City or Town: Permit/License #
Issuing Authority (circle one):
1. Brea- r- d- of- Health 2 -- nH n- 3tparlme it 3. City /Tuwu Cleih__4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
,
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �, ` Not Applicable ❑
Name of License Holder : Pc ;
License Number
Expiration D to
413 '15Isc "' t A 1 ►o
Signatur Telephone
9. Registered Home; Improvement.Cont rotor - .w Not Applicable ❑
\A pe s, ` ' ,QA.. vatic \3i 3V4
Company Name Registrati umber
A b\ i \b 1l
Addr s TT Expiration ate
N ‘k r rkt■ 06 ` �\� • b Telephone '' , G r��iy '. fk
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG.L. c. 152, § 25C(6j)
Workers Compensation Insurance affiday ust be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil ' g permit.
Signed Affidavit Attached Yes No ❑
1 . `` .wh
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 respo ibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws d State of Massachusetts General -La- wsAnnotated.
Homeowner Signature
i
,,,,,/
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) v re
Roofing n
Or Doors D
Accessory Bldg. ❑ Demolition Eil New Signs [❑] Decks [D Siding [prr Other [0]
Brief cription f Pr posed i ` i �j ��
Work: Alt Z Al.li,. I R r 5til ∎ 1 �44`A�`4�i� A- •etiviNN c 1 91ip1f f-t� 14,wC+ ,,,
Alteration of existing bed m' Yes 4/ No Adding ne bedroom Yes Y' No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
s. If. "NeW house - and ..arMad itiotito .:existing..hOustnci =complete the following:
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. Z Dimensions
e. Number of stories?
4
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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, k N 1 P.-`N` 1 W , , as Owner of the subject
property
- hera.Dy atith size
to a on m behalf, in all matters relative t� authorized by this building permit application.
Si nature of n er Date
I, I tAtti‘ kQ"!t , as /Authorized
Agent hereby declare that the s tements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed un er the pains and penalties of perjury.
Pri
i
Signature of t wner /Agent 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
Lot Size
Frontage
Setbacks Front
Side L:i_ ____ R.
Rear
Building Height -
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved ? ,
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 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 #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 410 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 s
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
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
-, , , r-4 7 Deartrnent Use og '
City of Northampton Stetus t #P
Building Department C�t3r e Per it � '; '
212 Main Street � s '
S �uveri�p #�c A�€a�Iabt[tty � . � - ' �
Room 100 War/VVeltAyariablf
Northampton, MA 01060 Two Sets af Structural 'Plans
phone 413 - 587 -1240 Fax 413 - 587 -1272 • .Piot/SSte,,Pians
Q
.=.-.,,,,,,,,,,,,--,-
F A
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOyI H.' OI E 1 TI VOW AIV LY r�
SECTION 1 - SITE INFORMATION i ,,,,1
JUL 1 3 2009 L.�
1.1 Property Address:
This section to be completed by office
S. L 1)4 VIN. 1' Map i r . ; Let ' 1 'r NS Unit
c\S 04 �'*/ Zane Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of RecordI . 4 �"'�C. (s \ )
N: - (Pri Vb ✓N t W L A v Current Mailing Addre
Telephone 1'
3 --9S' Zo l.iy
Si� nature
2.2 Authorized Agent:
%Mk-AN ,O,Dx b1 Clf1S‘ R bk ;3Z
•+ y. ,fin? Cu ent ailing Address.
Signat r_ Te hone
SECTIO ° 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated- Cost - (Dollars) -to- be Offtcial Use Only
completed by permit applicant
1. Building W4001) (a) Building Permit Fee
2. Electrical Q i (b) Estimated Total Cost of
1 Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) ■
5. Fire Protection c�
6. Total= (1 +2 +3 +4 +5) )a -' Check Number
- TliisSec'tion: or Officiaf"ltse
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
0
)4TBURTS PIT RD BP -2010 -0045
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 6 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 -0045
Project # JS- 2010 - 000057
Est. Cost: $60.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANDY 077431
Lot Size(so. ft.): 52533.36 Owner: I3 NJAi MI . RANDE LCIS DUBIN
Zoning: S14100)/ Applicant: MAi -:K LH.NL' Y
AT: 841 BURTS PIT RD
Applicant Address: P Phone: Insurance:
P O BOX 61 (413) 625 -6999 O
ASHFIELDMA01330 -0061 ISSUED ON: 7/15/200 0:00:00
TO PERFORM THE FOLLOWING WORN: REPAIR SIDING ,INSTALL PULL DOWN STAIR
IN GARAGE
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: /0 --9 -e? A Final: t'
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Cl .. 6 -7.0 V : T : ,:4 . r .
Final: 1 9""'` 7 Smoke: Final: 1k 1 i/2. 6 9 ✓,
THIS PERMIT MAY BE REVOKED BY THE CPT 11W NORTHAMPTON UPON VIOL ' ON OF
ANY OF ITS RULES AND REGULATIONS.
it izzio) ot ee
Certificate of Occupancy * Sif..at►yt
FeeTypE Date Paid: Amours;
Building 7/15/2009 0 :00:00 $60.00
212 Main Street, Phone (413) 587-1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
F