36-206 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
-- — —pe its in- conjunction.. to_the buildingpermitissued,. 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.
ate_.w-
Address of work
location
1 -
I The Commonwealth of Massachusetts
�, ,..—.. Department of Industrial Accidents
= ,... 5 i = fl Office of Investigations •
Ai
pp 600 Washington Street
f Boston, MA 02111
www.massgov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): V 6 14 Lt - c &4-C, k- 00--.0
Address: a ?) S - tAA-- *Q
City /State /Zip: S 4Qft.& LAi it . \j.k4&— Phone #: y 1?) - L. (o 9 `l `I cc
Are you an employer? Check the appropriate box: Type of project (required): /'
1. I am a employ er with Lc - 4. fl I am a general contractor and I
6. ❑ New 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. Remodeling
shin ..s,rl have no employees These sub - contractors have. 8. ❑ Demolition
for me in any capacity. employees and have workers'
working
Y aP ty. 9. Q Building addition
[No workers' comp. insurance comp ,.ranee
re 1c al r airs or additions
uired. repairs required.] 5. 0 We are a corporation and its o rersaave xercised.their 11. Pkmabbn repairs 3. ill I am a horneoufiser"tieingII werk — ___ -_- Q g airs or additions eP
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. ❑ 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 as 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. s Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date: 2 I y I 10
� Job Site Address: W :.!..�. L :__ _� City /State /Zip:' � Ae4-
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 crimina.I penalties of a
fine up to $1 and/or 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: le advised that a copy of this statement may forwarded to the Office of
Investigations • the DIA for insurance coverage verification
I do hereby c 1 under d e pains and penalties ofperjury that the infonnation provided.abave isir _and_correct- _ -
Signature: 111Pr Date- 1 L ®`1 _ •
Phone #: 4 t; ' (i i' CI SA. er
It - Official use only. Do not write'fi this area; to -be compteted by city o r sown officiaL
City or Town: Permit/License #
Issuing Authority (circle one):
:I: Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other r
t_
Contact Person: Phone #:
T s
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : vC") tr\" .
01-0¢ -11 - .. CS 1 1 3 6. `i
License Number
3 S . t A k A - I o /( `f / ( o
Addres Expiration Date
l er
Signature I Telephone
9. Register."ed Ho pr et de n tCo n t r act ur Not Applicable ❑
SA —ftzi Cot-t C - ( 6 &o
Company Name ` t / Registration Number
?� S . "t i 4at U � r V ra 21 44- AY- 1/ L — ( ( 9 / Address Expiration ate l
Telephone v (o S • 1 qci
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 ❑
Itt44MORtektAWiler: 1:4:(14 t Mail
The_current_exemption for "homeowners" wa extenrlerl to include 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. w
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" c ertifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances ` a e d`Loca'1"" • i ... - -o E = ®- neral- LawsAnnotated.
Homeowner Signature
, T
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors D
1
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [D Siding [D] Other [p]
Brief Description of Proposed �_
Work: K]Tc ' t24 (kVi- t la , 14.,,L) cL Woks i (f 6i44-(s (0 3 ( sL
Alteration of existing bedroom Yes V o Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
ea ' :lf..Neiklibuseand- `oradditlor _t existing housirui oinptetettie foliowanq:
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
I, 3 •vk N J J A. r'`2_ S , as Owner of the subject
property
hereby authorize 343 L cS «- IC `f- `'t
to act on my behalf, in all matters relative to work authorized by this building permit application. „loc.,
H Signature of Owner Date
1, "� S i , as Owner /Authorized
Agent hereby declare that the statements and information on foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed undcr the pain and penalties of perjury.
JO Lofit 4' f giirrAi--4-6-
Print Name
� � S. j 1
Signature o * nt ( Oat:
oIIII
IA6 6,
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 R.'..__ L:, „, z R:.,
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
# of Parking S ces
Fill:
(volume & Location).
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW a YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW a YES
IF YES: enter Books j Page, 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 preperty? YES 0 NO Cr
IF YES, describe size, type and location:
D: -- Are there any proposed c angel o or a i o stgns ntended the — property ? YES 0 NO cy
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.
0 1111.
• ______ C ity of Northampton S�a f PeTt
Building Department C ul �P rt 4
212 Main Street s omas � �1(�
3
Room 100 i } 1 -t ;
9 2009 Northanjpton, MA 01060 r °c� : l i'
yet se f i .. '. s
� �� phone 413;587- 40 Fax 413 - 587 -1272 Mans * �
APPLICATION TO C 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
c -`°I u) ANktvf- Map Lot Unit
T L— uL , , 01 0 (o l- Zone Overlay District
Elm St. CB District
SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
F I o we"t 4C.. 1 ANA,- 0 t 3 6 7_
Telephone 4 t Z_ 510 3 Z k Z
Signatu
2.2 Authorized Agent: Sui-Lfvea.ciii-42
- 0 ki 1/ + S Name (Print) �'� Current Mailing Address: O 7 c
Signature Telephone
• SECTION 3 STIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building'' Permit Fee
72,C S()
2. Electrical (b) Estimated Total Cost of
6 , S CPD Construction from (6)
3. Plumbing Building Permit Fee
ij i> t C
4. Mechanical (HVAC)
5. Fire Protection �
B 8 3 . a6
6. Total (1 +2 +3 +4 +5) S 8 O D Check Number l)(in K 6�1�
.. This Section Far Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner /Inspectorof Buildings _ Date
i
File # BP- 2010 -0195
APPLICANT /CONTACT PERSON SACKREY CONSTRUCTION
ADDRESS/PHONE 83 SOUTH MAIN ST SUNDERLAND (413) 665 -9995 Q
PROPERTY LOCATION 59 WINTERBERRY LN
MAP 36 PARCEL 206 001 ZONE SR(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 6' r
Fee Paid c9
J
Typeof Construction: RENOVATE KITCHEN, NEW FLOORS,CABINETS & COUNTERS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 040714
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved 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
///,'
A.07
ture of Buil . mg Official Date
lance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
rents and obtain all required permits from Board of Health, Conservation Commission, Department
works and other applicable permit granting authorities.
nces are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
.g & Development for more information.
59 WINTERBERRY LN BP- 2010 -0195
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 206 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 -0195
Project # JS- 2010- 000238
Est. Cost: $88000.00
Fee: $528.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SACKREY CONSTRUCTION 040714
Lot Size(sq. ft.): 45738.00 Owner: JAMES JOVAN
Zoning: SR(100)/ Applicant: SACKREY CONSTRUCTION
AT: 59 WINTERBERRY LN
Applicant Address: Phone: Insurance:
83 SOUTH MAIN ST (413) 665 -9995 0 Workers
Compensation
SUNDERLANDMA01375 ISSUED ON:8/27/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: RENOVATE KITCHEN, NEW
FLOORS,CABINETS & COUNTERS
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 f z /�_ House # Foundation:
!` i ( fi b Driveway Final:
Final: f --g.„ 1/ Final:/ ......2 P ,/ /
J / \ v Rough Frame
LJf` a ` 1
Gas: Fire Department Fireplace /Chimney: " °l/
.
Rough: i♦t- "' 0, Oil: Insulation; I
l
�/
J � bra j ��
Final: / f a� ,/' Smoke: Final: ® K p 3
I� l 10 L
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupanc Signature:
FeeType: Date Paid: Amount:
Building 8/27/2009 0:00:00 $528.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo