31D-224 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, act as their own construthpn 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 backfhl),
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 occupancv
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
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 DIELAY the project until such time as the proper permits and inspections are
made
( A itig understand the above.
■ .(Ho e ner /resident s ature requesting exemption)
I will . 1 to - ' edule all req ed building inspections necessary for the building permit
issued to''. e.
Date/
2,6q)
Address of work
location 5zittA
. ..e . r • ,.
. The Commonwealth of Massachuse
Department of Indus Accidents
illk •■•.:......" . il ri
8 =.41..==.....`' Office of Investigation&
600 Washington Street
.
s -..---Att— ri Boston, MA 02111 .
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wv.mass.gov/dia
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-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electric'ians/Plumbers
Applicant Information • Please Print LeEiblv
Name (BusineseOrganization/Indivirin4): ,
. ! -
• - Address: . ,.. •
City/State/Zip: - . Phone.#: • -
. ,
Are you an employer? Check the appropriatebox: • .Type of project (required): i
1.0 I am a employer with 4•. 0 I am a general contractor and I
6. 0 New coistruetion
have hired the sub-contractors
employees (full and/or part-time).
2_0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 P.cmodehrig
•
These sub.-contractors have S. 0 Demolition
ship and have no .}loyees
working forme m any capacity. ix_oill.PYPre4 _ -agilla_fe Workers' : .-_ - it a ii *,. a., 4 4liti _ . .
on
[No workers' comp-. insurance - -
10.0 -11ectrical repairs or additions
, . 5. El We are a corporation and its
3 I am a homeowner doing all work officers hair 4xeraisecl their .
1 11.0 Plumbing repairs or additions .
myself [No workers' comp. • nett Of exemption per MGL 1---1.;•.
12.Li icoof repairs . •
insurance requ t . . - . 152, §1(4), and we have no • •
, .. . employees: [No workers' • 13.[:] Other r -
.
. . - comp. insurance reqUired.j. - ' • • . .
*Any applicant-that checks box n must also fill out the section below showing theirworkers compensation policy jean:Intim; . . ,..: .
1. Homeovmeri 'who submit this affidavit intfittating they are doing all work and the hire outside ccmtraCtori must submit anew affidavit indicating such.
:contractors that check this box mustattached an additional sheet showing the name of the stibcontractars and state wietherornotthose.entities have
employees. If the sub-contractorshzie employeeS, they mustprovidi their' wOrkers' cortm. poficy number. ,
an employer that is providing }porkers!' compensation insurance for my einplOyees. Below is the policy and job site
information. • .
. -
Insurance Company Name: • - .
. .
. • .
Policy # or Self-ini. Lic. # Expiration Date: - . - • I ,
' .
. . .
Job Site Address: : . ... City/Staft/Zip:'
. Attach a copy of the workers' compensation poi:ley declaration page (showing the policy nuntlier. ancle3:piration date).
. . _
_
. • . .. ,
Failure to secure coverage as reqiiired'iiiicte SeCtroil 152 can lead to the iin Ofaintittiliiiiiiilties 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 S250.00 a day against the violator Be advised That a copy of this statement may be forwarded to the•Offibeie
'EVestteattoiii for in'sitrandedoveiae Verification - _ . - __ : : ...,, :::,- ,:....:,.....-,_. -:•_,:::-:.....-......,,... .... „..._ . „ „.„
tdoltireky_ — . , . ,.. , : /7, , ., , pen. ,1 ," . olperjury tharthe infornuitionpro . , , _aboOt ,..., _tuidiorCI '
1100
/ . 1 /7
Vti* • -tiie: Ai ■4 . ■ 1A4 i i Aii ' rA2Lir - ::.7: •-• • ..1; _ Z . .
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Phone it: i-t-i / I - .7 , -,.._, , . c _ i .7, II :-•:- *: ' • . * ' - • ' . .
.. . ....._ .,.-.,--.
• Official u.se only. Do not write Ili this area, to be completed by city Or townofficiaL
. •
City or Town: .- Permi't/License # • , _ .
Issuing Authority (circle one):
:1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electricalisispector 5. Plumbing Inspector
6. Other . 0 0 • . •
Contact Person: Phone #:
• •
r r
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9 Renistereitl-I1ome<i o __ X
rt!tp'#�ci�eit�f�nt£ott�lraa�pr _�,�,�,;W �.�,�,�;�; ; �,; y �,alif$EMit Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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 ❑
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 re .onsibility for com• ance with the State Building Code, City of
Northampton Ordinances, St a ' s :nd State , ■ a •achusetts General Laws Annotated.
/ Homeowner Signature Aut.
•
� f
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
N ew House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing • ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [Cr Other [0]
Work:
Brief Deseeript (— pp t of,1.1l&e c * K00
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
a, if l eWlorx `and &w adttt0i1 o zi tii q. trolaslfra, Gdtnptefe th ttandikip:
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
, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
, as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signe• I drr the pains and penalties of perjury.
1). mid
Print Na - ' Iv
U( Signature of Owner /Ag- 't ;ate
s
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete In1 rmatiori_ ' °
r :r1
Existing Proposed Required by Zon g —/
This column tobe fill din by
Building Department ) it4 j
1
' Lot Size 3 — e e" y
J r`a*
Frontage
Setbacks Front i 1
S ide L: ! R: 1 L: _ i R:`,, 3'
Rear = -
I
Building Height f 1 i
:
Bldg. Square Footage r ------ 1, I-1 % 1 J
Open Space Footage %
(Lot area minus bldg & paved "-----j "
parking)
E
# of Parking Spaces
Fill: I 1 I
(volume & Location) l ---•
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:I '
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book P Pagel 1 and /or Document #r
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES Q
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: 1
D. Are there any proposed changes to or additions of signs intended 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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
--- City of Northampton ��� �;
Building Department .',4,41-.11,441/. r- 4 ;r ; ,� ,, i l'z_
212 Main Street _ ' '
1
2011 Room 100 . > ,@
Northampton, MA 01060
on = 413- 587 -1240 Fax 413- 587 -1272
.- . .tl,..- ....41•. -- '';'_ -- - J ' i' s , s � - � " , z' .� '..
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1 Pro e Address:
This section to be completed by office
eouth,s1-. iC/ q Map Lot Unit
�� /�6 � Zone ' Overlay District
� �/ Elm St. District CB DistrIet
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Na • ,, / - Current Mailing Address:
L/, All � � A Telephone ( .5 r 5 -7 . 5-;
Signature '[
9
2.2 Authorize. • gent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dolla • be Official Use Only
com leted by permit a. - nt
1. Building T� 9 ? 71 (a) Building Permit Fee
-f ,.
(1
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number 6 1 7 d ` � �
This Section For Official Use Only / �'
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
69 OLD SOUTH ST BP- 2011 -0787
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31D - 224 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP- 2011 -0787
Project # JS- 2011- 001296
Est. Cost: $500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 15420.24 Owner: HYNES ELIZABETH & ELIZABETH MALLOY
Zoning: CB(7)/URC(93)/ Applicant: HYNES ELIZABETH & ELIZABETH MALLOY
AT: 69 OLD SOUTH ST
Applicant Address: Phone: Insurance:
69 OLD SOUTH ST (413) 575 -6404 0
NORTHAMPTONMA01060 ISSUED ON:3/31/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR 4 SQ ROOF & 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 3/31/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner