32A-175 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 b a aware that
by doing so you become responsible for compliance with state building codes and
regulations The inspectionprocess requires that the buildi d epartment 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
--
pennits_in_conjunction to the_building_permitissued, 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 me.
Address of work
location
The Commonwealth of Massachusetts
A - Department of Industrial Accidents
— 6 — r Office of Investigations
_ s � 1 =
600 Washington Street
e. = -- # Boston, MA 02111
' 1/4B-' � . www.mass gov /dda •
-Workers' Compensation Insurance Affidavit Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual). AtieLA 47),e V / l?L
Address: 60X- 1/ / City /State/Zip: ce)
QJ ( A1 Phone #: (/3 63 t/ 22_ O
Are you an employer? Check the appropriate box: Type of project (required): i
1. ❑ I am a employer with 4.. 0 I am a general contractor and I
6. ❑ New construction
employees (full and/or part- time).* have hired the sub- contractors
2.16.1 I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no Ioy ees These sub - contractors have. g. 0 Demolition
working for Y ca pme in an ac ty employees and have workers'
__- 9. n Budding addition
[No workers' comp. insurance _ comp_ ansitrance.
required.) 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3 Q I am a homeowner-da3ng-a:ll avork- si ce _have rcised it 11.0 Plumbing 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
co r
employees. [No workers' 13.* Other eiciejr
comp. insurance required }. .Q '1 / )Z11/
*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 mustpravide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employee& Below is the policy and job site
information
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City /Stafe/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 $1,500.00 and/or one =year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fi
of up to $250.00 a day against the violator: 13e advised that a copy of this statement maybe forwarded to the Office of
Investinations of the DIA for insurance coverage verification
/do hereb ertify under the pains and pen , perjury that the information provided_ , ove islrue_ and_correcL
O
AV 3 g �.�,y -
Phone #: Z1'`�
Official use only. Do not vrzte in this area, to be completed by city or town ofciaL
City or Town: Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 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 : C `- �` 0 "'I �-kt i> 6 y/o '7 / 20/0
License NtImber
'void. Lit T 7J 7 i - CDi4tA O/) 0%yl
Address Expiration Date
� _m,..MP i���_ t3 Y 22-s-0 •'7. -
,7�'/ Telephone
9... Registered„ Home,,improvefnent :Contractor k" ,, .. ..., , . i ,.;y,,.,. ..L .,4. Not Applicable ❑
iyZ ?/c
-
Company Name Registration Number
lam. - ) o W2, Cv O
Address ,��,� �/ V/3 63 ti Expte
P ?7�x -t// �'/�' /Z'f -D/ Q Telephone 23
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 .:- ei e Q �et ii xe 1= � p e
The_current_exemption for . "homeowners" was extended to include Owner 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 referenceto 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
port -amp on Or•mances ' . e :n.
,• .+ • . ' • :. _� - , _ - r - Laaus Annotated.
Homeowner Signature
r
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [[] Siding [D] Other [D]
of Descripti of Proposed
ork: 4p { ` C-1 l e6.1 9 4 9iet- , e4eri bl d0 f
Alteration of existing bedroom Yes 1/1Clo Adding new bedroom Yes v No
Attached Narrative . Renovating unfinished basement Yes t.--Pitf
Plans Attached Roll - Sheet
sa ittsiew tioulse artd or. addition to ixistind housing, com plete 'lie 6116 lriq:
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, , as Owner of the subject
property
hereby authorize
to act
of Owner act on my behalf, in all matters relative to work authorized by this building permit application.
Signature Date
i, A A 0 0 Ir 1�� as Owner /Authorized
Agent here y declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
C-( -r v r,...:iu5
P nt Name
/�' r� ■ ■ '
Signature of Owner /Age 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.;__._ R. __ w L `....._ ._._' R ._.._ .
Rear
Building Height
Bldg. Square Footage % � (�
Open Space Footage ,.. _.. %
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill: A
(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:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book 1 Page? and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 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
IF YES, describe size, type and location:
D: `Are - tf�iere any proposed changes to or a pions o. signs inters ed fo ff e 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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
r
� ? � De � �
City of Northampton S t �l �sot -ei�`
Building Department : , t om 'f t y ei �. lt x
, k
v I ea` vat t ' � O t
12 Main Street °� ��" � �� ��_; ,��� �,
! '� Room 100 i t , x' a � " ,, 3` 04 l w
Northampton, MA 01060 raP rssb
phone 413 -587 -1240 Fax 413 - 587 -1272 Pti� eLttta � . b .,
de Q { ` ,* � : .
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 . SITE INFORMATION
1.1 P / ropertty Address:
This section to be completed by office
� b i �b � 6 (� l�l Map Lot Unit
Zone • ?- Overlay District
E District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: J .. ?) ,/ c /J i p ,Lam,,. /-
Name (Print) h 1 r J .. ' Current Mailing Address . n ( S
T elephone i g � � y �'
1,7 vv
Signature ■ lI Y 1 6
2.2 Authorized Accent: J�,
/Name (Print) L C L. re.„ 0 t) , ._ i J Current Mailing Address:
0 �..�I!f�
Signature ! Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
em Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1 . Building j� Do b (a) B Fee
/
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing _ Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection /y _
6. Total = (1 + 2 + 3 + 4 + 5) `(,)/ 0 O Check Number / !� 406—
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building .Commissioner /Inspector of Buildings Date
•
46, 56,& 66 BRIDGE ST BP- 2010 -0297
CIS #: COMMONWEALTH OF MASSACHUSETTS
Map:B : 32A -175 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 -0297
Project # JS- 2010- 000393
Est. Cost: $10000.00
Fee: $1 05.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MEASURE TWICE RENEWAL 094102
Lot Size(sq. ft.): 23261.04 Owner: NORTHAMPTON HISTORICAL SOCIETY DAMON HOUSE
Zoning: CB(100)/ Applicant: MEASURE TWICE RENEWAL
AT: 46, 56,& 66 BRIDGE ST
Applicant Address: Phone: Insurance:
P 0 BOX 41 (413) 634 -2250
PLAINFIELDMA01070 ISSUED ON :9/18/2009 0 :00 :00
TO PERFORM THE FOLLOWING WORK: REPLACE CEDAR SIDING & EXTERIOR DOOR
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 9/18/2009 0:00:00 $105.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo