31B-281 (3) 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
jermits 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
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
•1..' T
le .. „..
The Commonwealth of Massachusetts
_.,-- Department of Indus Accidents
Office of Investigations .
* ....... 1=.- r.
=Vilks- 5 600 Washington Street
Boston, MA 02111 .
,... -4=
„.-..-.- . , www.mass.gov/dia .
•
- Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information c ,..._ Please Prin Legibly
Name t, e q_ tce-i -0).-r., 51
• , F
Address: 61i e/ V [ et-J • -
-1. _....'
City/State/Zip: .6.,51{l 1 0 A phone.#:
°(().17 gr -:)-9V - ( 16 .5 a-
Are ru an employer? Check the 4propriate box: 'I'ype of project (required): I
1. Bosn am a employer with 3 4• 0 I am a general contractor and I .
6
employees (full and/or . El New construction
have hired the sub-contractors
part-time).*
listed on the attached sheet 7. 0 R.emodelilig
2. E] I am a sole proprietor or partner-
l'hese sub-contractors have
ship and have no aIoyees 8. 0 Demoliti on
working for me in any capacity employees and have workers
9 0 Building addition
[No workers' comp. insurance
required.] 5. 0 We are a corpor 10.0 Electrical repairs or additions
ation and its
3. 0 I am a homeowner doing all work officers have txercisecl their
t 11.C1 P ing repairs or additions
myself [IsTo 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.EI Other
comp- insurance required-I
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infonnation. - :
t Homeowners who submit this affidivit indicating they are doing all work and then bfre outside -contractors must submit a new affidavit indicating garb
: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. lithe sub-contractors have employees, they must provide their workers' comp. policy number.
.1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
- 7 / A A 1 2 £ 772/ 4 7
Insurance Company Name : G ( / i ( I i I 1./ ( U ( tt j . • .
Policy # or Self-ins. Lic. #: - 7 6 ( ., 0 30 t) / -Z..0 ( C Expiration Date:
Job Si Ad 0 dress: Ci of/
(5 P C/S
- - .
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expirati 2 date).
Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of Criminit penalties of a
fine up to S1,500.00 and/or one-year implisonment, as well as civil penalties in the form of a STOP WORICOIUDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
afeitization,s DIA. for nisnrance coverage verification. , ,...
%do Iseribj" riz:6iMilL4 pan. , p altie' s of p .. - --1 that the infarmatiO n proviciedaboT e_c.ii'tii ii;diCiriict.:__ _.
Si .. - time: A4+4111 1//augtAtik....z..._ , 22- /
Datz:
Phone ifi: . b ([ : --- 1 9.Y — YG v 1,"
Official use only. Do not write in this area, to be completed by city or town officiaL
• •
City or Town: '• Permit/License #
eelemare..,•,...... ....,
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector
6. Other , fr . .
■
Contact Person: Phone #:
r
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ` , 1 Q �.
t J F (c v2 f V ✓ 0 67I
License Number 13 Addr Expirat /Dat
Fgnature Telephone
r /
rr Not Applicable ❑
9, =;R � ts#e = d Hor►m'• Itn ®rovemein n3lractor r A � � �. �..� : �«. �- � ...a,.� .��,....., �� PP
' 'i f "_ Ca - S L J.Z-�
R e i rati n Number
Company Name g
R; Z- -elf e./c 6 6 7
Addr ss Ex rati n Date
,.._k.,.. S ri r- T elephone 1�.--
—
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affida ' must 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 ❑
11. f.4- H O i .:xem 'i do
The current exemption for "homeo -rs" was extended to include Ownerrccupied Dwellines of one (1) or two(2) families
and to allow such homeowner to engag- . individual for hire who d• not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Editio Section 108.3.5.1.
Definition of Homeowner: Person (s) who .wn a parcel of 1. . on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family d ; ling, attac • or detached structures accessory to such use and/ or farm
structures. A person who constructs more tha one h. e in a two -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building • • al, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under building permit.
As acting Construction Supervisor your press ce o the job site will be required from time to time, during and upon
completion of the work for which this permi s issued.
Also be advised that with reference to Ch. er 152 (Wo ers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in • - ath) of the Mas • chusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you and this permit.
The undersigned "homeowner" ce ' es and assumes respo .ibility for compliance with the State Building Code, City of
Northampton Ordinances, State . d Local Zoning Laws and tate 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 El
Accessory Bldg. ❑ Demolition El New Signs [0] Decks [C] Siding [0] Other [0]
Brief Description of Proposed • • . ,
Work: I C e , d 3 (e.S
Alteration of existing bedroom Yes No Adding ew bedroom es No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa _ if Mew hociee and t r idr ition t ' xis it q hol s nq c ipt e.the:fo11 fiifla:
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 a E Pi
to act on y behalf, i gall . : rs rel. ive to work authorized by this building permit application.
- _ �.:. 1. z�- z7s - —1)
Sign u - o Owner Date
l � Ct j4 M , as Owne Authorize
Agent hereby declare that the statements and in rmation on the foregoing application are true and accurate, to the best of m w edge
and belief.
Signed under the pains a.. renalties of perjury.
- , a 1 ttx ., r
Print ame ` r7
d owylimilej
Sign . tur. of Owner / • 2e t Da •
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning / ' . -
This columnRQ be filled in by i . 1►
-- Building Deparfl}f�t
4
4 " ' /
Lot Size r ? _ - r'
Frontage I . _ _ 1
Setbacks Front l `'
Side L: _ L: mi R: _i L:L 4 R:.
Rear E
Building Height
Bldg. Square Footage � = % I = f l
Open Space Footage % -,
(Lot area minus bldg & paved i i . o w...
parking)
# of Parking Spaces
,_
Fill: 1 I
(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:; I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book 1 1 Pagel i and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q 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 property? YES 0 NO 0
IF YES, describe size, type and location: 6
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
IF YES, describe size, type and location: I
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.
. Alit.... , ..
V C ity of Northampton 8
ctO\ uilding Department u4, ? D ° m e :,` ` o-
#11. Gj 12 Main Street ` 1 t.6 - Room 100 fit' e Q - 1. 4
` `� Northampton, MA 01060 ® ` ' � . f e f £
� � `�• hone 413- 587 -1240 Fax 413- 587 -1272 . - '‘ r �, ;, .,
t ., � '°, £
• PPLICATION 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
,y % ` �-1i Map Lot U nit
A) t r /414- - Zone Overlay District
Elm St District CB Dist
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT I
2.1 Owner of Record: I
1ic.) ,3v N " C as i ,t;z. '( .._ /
)<N 1 i (Pr t i L /) J Cuq y 3,,....., r td d 1 / -' n ij l�
- {J, � tF lr� 0
one r
� Teleph( �
*nature q 1 3 5 3 7.
2.2 Authorized Agent: / k
N me (Print) K Current Mailing Address: _1
/� , - 4 _ / L t �
` � - 9 5 f -C t y i 0 s"
!!!rrr' G
S . - ure i Telephone
5 ION 3 - E (MATED CONSTRU 4 ION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection ,c,
6. Total= (1 +2 +3 +4 +5) /I, !6 a t Check Number / b � ^.,
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
15 BUTLER PL BP- 2011 -0767
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 211 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-2011-0767
Project # JS- 2011- 001267
Est. Cost: $7600.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WEATHERPROOF CONSTRUCTIONINC 062833
Lot Size(sq. ft.): 8102.16 Owner: CAVANAUGH J MICHAEL & PATRICIA
Zoning: URC(100)/ Applicant: WEATHERPROOF CONSTRUCTIONINC
AT: 15 BUTLER PL
Applicant Address: Phone: Insurance:
24B NORTHAMPTON ST (508) 294 -4052 () WC
EASTHAM PTON MA01027 ISSUED ON:3/28/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 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:
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 3/28/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner