32-038 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 fondly
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 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
•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 .
l; 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
7
, .
The Commonwealth of Massachusetts
I
=„1.-=2.----- ., Department of Industria I AOcidents
5,
..-:-....-::::---- ---
Office of brOestigation:s'
600 Washington Street •
Boston, 1PL4 02111 . • .
wwwmass o.vv/dia
, ... . 1,
•
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information - Please Print Legibli7 . •:',
• ,...._ .
,.._-
Name pusineseorganizationfindivien.D: /0 / 7 / ---- 7/_7 7 .
. . , ...g., .
• ! .
• • Address: 7 -9 tz,----e 5 7 ------ -
. . •
,c- ---7 e._ / .-.. —7 ,
City/State/Zip: ilty-64,7V - t. 7 /T Phone.#: L) / -I / / / -
Are you an employer? Check the appropriatebox: • . •Type of project (required): 7
• 1. 0 I am a employer with 4.. 0 I ama general contractor and I
6. 0 New coistraCtion.
have hired the sub-contractors
employees (fall and/or part-time).*
listed on theattached sheet: 7. 0 Remodeling .
2 I am a sole proprietor or partner-
. shipancl have no employees These sub-contractors have. .8. 0 Demolition • .
worldni forme in any capaaity. klgaSk3Treg•-..-4-d- :worker. s' - 9 . iidie - d . • .
[1■10 workers" comp-. insurance
- repairs •
required.1 - . .
. 5. 0 We are a corporation and its 100 El eCirical or additions 3. o I am a homeowner doing all work officers haire4keraised their . i i.0 Plan:thing repairs or additiOns
/ .
myself No workers' cOro/3. . right of exemption per MGL
12.0 Roof repairs
insurance required.] t • • . : ,c. 152, §1(4); and we have no . .
employees: [No workers'. 13 6thel. r ..
- . : . • . •
' . ' • : • • . comp insurance reqUited.j. : : • - : .: ..
*Any applicant that checks box #1 must also fin out the section belowshowing theirworkere conpensation policy infonnatien. • '.,. •
t Homeowner* who submit thii atildit.inclicatini they re doing all work and then hire outside contractors must submit anew affidavit indicating such.
*Contract= that check this box mustattached an additional sheet showing the name or the subcontractors and state whether or notthose•entities have
einployees. lithe Mb-contraCtors employees; they must providitheir workers comp poliey number. . . • , : .7. : 'I . .. ..
•
• lam an employer that ispi-oviding workers' compensation insurance for my eiizplayees. Below is the policyandjobrsite
information. . . • .
•
Insurance Company Name: • - . . .. . -
. • . . . . . .
Policy # or Self-ins. Lic. #: . Expiration Date: - ' - .• I ,
• • .
. . . .. . .
Job Site Address: • : . - '' City/State/Zip:'. :- ' . • . • • . - .•
• Attach a copy of the workers': compensation pokey declaration page'(showing the policy nuinber andespiration date).
Failure to secure coverage as reqiiireliiiidiir Seetroit25A - C. 152 can lead to the imposition of'aiiiiiiii41Penalties of a
fine up to S1,500.00 and/or one-year iminisonme4' as well as civil penalties m the form ef a STOP WORK-ORDER and a fine
• °flip kr S250.90 a day a: .■.•1 ,... Violater. Be advised that a copy-of tliis statement may be privaided.tothe.Git'ce of , .:,•_,,_ '
- Sieititarrolis ofthe 9 : .'?qns i e - . - 7 ..
- - d er th , , a' , .and penaitiei olperjrayihaithe'in:fo'rMatiUnpririFidek;lbo-00 ri-Prt.' . ...
. _ ._ ........... . .. . ---- -...,... . .
.. . .
Signature: ' : ..
- . : . • Date; • • •
• , .
• — • , • . - •
Phone ii: D 7 67 7/ 7_ ,..-_-, : ' . . _ • .
Official use only Do not write in this area, to be completed & eft; O r toWnerthiaL
. . .
City or Town Permit/License #
: .
Issuing Authority (circle one):
Contact 1 . B 9 h r er d r °
Health
'
*- ' . .
2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector
6.Other
.
.
. .
• -
. • •
w
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su rvisor: j Not • •plicable ❑
Name of License Holder : C'I'A 17 / 5 / { .0 /'1 ,6'
License ber
Address ' Expiration Date
5, /z 7/
Signature i / �' Telephone
r-
rs erri �� f 9 • - N ot Applicable
��#, 2episte� i�� '+taepro�e�� a »�rac#r' •�`�_�.�,����,�� ,;:per � � � ��•.w.f �, p
J 1 rt Ce-// 7 S / f /*/ V r3
Company Name Registr i n Number
Adcliqss Expir ion Date
r /41(r7-41 °1 i ( I. Telephone ! 7 r!
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 ❑
11 a tionn
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 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) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [C]] Other [O]
Brief Description . - roposed i 1/( 1 l S('"---'
� �"
Work: e e ■ ► `.• . ! _ 7 VW mo k
c -
Alteration of existin g bedroo _ No Adding new bedroom No
Attached Narrative / 7i. Renovating unfinished basemedt '' Yes No
n -
Plans Attached Roll Sheet
� v, r ri o
0-
a, f w hous an o I ° h t o x ist h i nq. mo i Mefe the ohO
s wi na:
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. Di ensi n
e. Number of stories?
f. Method of heating? Fir places or oodstoves 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, , as Owner of the subject
property
hereby authorize
to on my behalf, in I matters relative to work authorized by this building permit application.
idea-- / ( Lu (
Signature of Owner Date /$ it
I, h... '- /1° -.
/t% /, / � "r`f /Se�,,,s t Od 0712 !/6 CV�.5 /� ( - , as Owner /Authorized
Agent hereby declare that the statements and information ,
on on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
..- M c6Z 4560.se
Print Name
C aW ti--. cr 1 ‘• , tx --> C--• • / h l l
Signature of Owner /Agent Date
j
4
, '
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete In .tion
Existing Proposed Required by Z. ing
This column to . filled ` by
Building Depa • t ""E:' ` iea
Lot Size 1 a
Frontage ' • �` ' A, { r
Setbacks Front i ! i
Side I; 1 R:' L:` R:i
Rear
i►� ill 1
Building Height .4 —
— ---
Bldg. Square Footage I % [ 1 i I
Open Space Footage i
(Lot area minus bldg & paved 1 ` 1 t � 1 77 , e
parking)
i Ilk
S' .e.
# of Parking Spaces - -
Fill: r .._A—��..•.. �.- _ ... .w. .u.... ., .,___.,.__:
(volume & Location) 1
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO ® 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 1 Page[ 4 and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
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 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
IF YES, describe size, type and location: S ■
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
. +
4,„, V01 ,, ; , ..• , i0.4e % 4- — City of Northampton i '40.°4441, �
c)(/‘ x Building Department - � ; oz�, 4
¢v c50 212 Main Street - . 4, ,
IC) Room 100 ,r. - . s a �. k� , t
alio Northampton, MA 01060 �
``',W 1 .
P L`
e , y • one 413- 587 -1240 Fax 413- 587 -1272 >
1 11.1 11P-y PLICATION TO CONSTRUCT, 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
1�E'Lti2e..L Iref'
d Rd . Map , . Lot Unit
NIY-I. 1 v►1 pi-in' Al A• c I o loo Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
- 'J -L ' , t. c' L _ I � , . ` 1, 1/ GG / / l i i / S 5r /ib2 / 6 r 4
Name (Print) Current Mailing Address.. g - qf 2 Lk /Vi-3 - 77 -524
at ,1 4. ■ ; N:.: - 7 Telephone /
• . nature
2.2 Authori ent:
Na ( P t) � Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Offic Use Only
completed by permit applicant
1. Building RO (a) Building Permit Fee
.( 0,6 s3tr_0‘ ...--
2. Electrical (b) Estimated Total Cost of
0 Construction from (6)
3. Plumbing Building Permit Fee
(2
4. Mechanical (HVAC)
5. Fire Protection (7
6. Total = (1 + 2 + 3 + 4 + 5) Check Number 4 f �pd
This Section For Official Use Only
Date
Building Permit Number: Issued:
Sig natu : ,l -z � i�
9
Building Commissioner /Inspector of Buildings Date
VENTURES FIELD RD BP -2011 -0861
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32 - 038 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofmg BUILDING PERMIT
Permit # BP- 2011 -0861
Project # JS-2011-001418
Est. Cost: $3000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RONALD MISTARKA 069836
Lot Size(sq. ft.): 66646.80 Owner: STANISEWSKI JOHN J & SANDRA A
Zoning: SC(1001/ Applicant: RONALD MISTARKA
AT: VENTURES FIELD RD
Applicant Address: Phone: Insurance:
122 WEST ST (413) 575 -1271
WEST HATFIELDMA01088 -0519 ISSUED ON:4 /29/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE METAL BARN 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: 01, tj / it
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REG LATI 0 N
Certificate of Occupanc ' . signature:
Amos /Ay 4,6.1.441•
FeeType: Date Paid: Amount:
Building 4/29/2011 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner