32C-206 (4) 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 construe ion 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 certif zate 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
iermits 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
1, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
K ,,,
issued to me.
Date
Address of work
location
• .. .
• The Commonwealth of Massachusetts
Department of Industrial Accidents . ,. .
P i --=•=• 1
Office of InivstigationS
600 Washington Street
7:r --- 41-1--- -- i Boston, MA 02111
_, 111,0•11 ,..,
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• ' www.mass.gov/di
• a , •
-Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers - -
-. .
Applicant Information -
Name (Businesi/Organiiation/Indivicin21):
• ° Please Print LegAblv
Address: • •
. .
‘., .
City/State/Zip: - . Phone.#: • -
Are you an employer? Check the appropriate•box: • . Type of project (recpur* ed): /
• 1. 0 I a loyer " • 0 I am a general contract° r and I " •
6. 0 New construction
have hired the sub-contractors
employees (full ancVor part-time).
listed on the'attadted sheet 7. 0 Remodelin
2.0 I ani a sole proprietor or partner-
These sub-contractors have •8• 0 Demolition • .
• ship grid. have no .>loyees
• working for me in any capacity. elMIP.3 Workers' . , ,•• .
[ - No . workers comp; insu • _ comp. j r.ouranc il:. •. _ _ _I—J_ ..Call . .° ,.
10.0 Electacal repairs or adcritions
required.] 5. 0 We are a corporation and its
• 3.U,I am a homeowner doing all work Officers haVe4xereisecl their • 11.0 Platabing repairs or additions
myself [No workers' corrp. - right of exemption per MGL
12.0 Roof repairs - . •
insurance required.] t
: p. 152, §1(4); and we have no • .,.._„
• •
employees: [No workers' 13.0 Other
' • • . .
comp insurance reqiiired.l. . . • • .
*Any applicant-that checks box #1 must also Ea our the section belowshowing theirworkess compensation policy information:
" •
I Homeownera who submit this afradaVit.intfidating they are doingall work and then hire outside contraetors must submit anew affidavit indicating such. .
Icontractcas that check this box must attached an additional sheet showing the nacre of the subcontractors and Site whetherornot those es have . •
ernployees. If the nth-contractorshaie empleryeea, they must provide their workers' comp policy number.
lam an employer that is providing workers' compensation insurance for my employees. Below is the poli4 and job site .
information.
" . • -
Insurance Company Name: • • .
. • -
Policy # of Self-ins. Lic. #: • • Expiration Data: - . - • : ,
. . .
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 reqiiired 152 can lead t5 the iiiiPosiiiiiii OradrainallienaIiies of a
fine up to $1,500.00 and/or one-year imprisonmeA as well as civil penalties in the forni of a STOP WOP,.1C.cgogR and a fine
of up to S250.00 a day against the violator. Be adyited*t a copy Of this statement may be forwarded to iiie Office Of
- Eiir — eititatiEnis• 'Of the for nistifinc dove:raze vErit • .
_ firrliii'eby_cerilhun i.• t.he painsami penalties olperjtoyiltrii infotntatiOnprovidiiab
Sienatrre: •-- • _ .. :
• Daft. , ' /
, --' / A . y72-D//
Phone i#: 1 /t( - 6 lig _i :7 -- -(0. 1 1 ..:-- .-012, '.• qi` 9 5 77
.-- Offielat use only Do not write in this area, to be completed by city or town
. .
City or nom:
"- Permit/License #
Issuing Authority (circle one): -
'
.. •
. 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Invector 5. Plumbing Inspector
1
6. Other
•
Contact Person:
Phone #: •
. -
. •
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of LIcen Holder :
License Number
Address iration Date
Signature teletabone
9.:Reaiiste eta06iri Not A livable ❑
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 ❑
iti *M mie , °: "; . E e on
The current exemption for "homeown " was extended to include Owner copied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an i 'vidual for hire who doe of possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Secti 108.3.5.1.
Definition of Homeowner: Person (s) who own a par = of lan • on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attac • • or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one h e in a • o - year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Of al, on a form ac : .table to the Building Official, that he /she shall be
responsible for all such work performed and the building permit.
As acting Construction Supervisor your • ence on the job site will be require m time to time, during and upon
completion of the work for which this • it is issued.
Also be advised that with refer- • - to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not iesulting 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) J Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other [0]
Work: fDescription of Proposed
r k C D fi E fNAA 1 i M „ i . fie
Alteration of existing bedroom Yes X No Adding new bedroom Yes x_ No
Attached Narrative Renovating unfinished basement Yes .: No
Plans Attached Roll - Sheet
sa .If f� vE se ern Ir ai c l l t c s i � .c lsl c i ip a ttre a ri n_ :
a. Use of building : One mily Two Family Other
b. Number of rooms in each fa 'ly unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new constru 'on. himensions
e. Number of stories?
f. Method of heating? ■ Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. M. check Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of w- -nds? Yes No. Is constru••'on within 100 yr. floodplain Yes No
j. Depth of basement or cell oor below finished grade
k. Will building confo o the Building and Zoning regulations? Yes • .
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 authoriz by this building pe ' application.
Signature of Owner Date
6 t tm. ' chNI- �- t . , a Owner uthorized
Agent hereby declare the t ents and informat on the foregoing application are true and accurate, to the 'best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
ScA‘x-C
Print Name J
// I
Signature of Owner /Agent Date
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Section 4. ZONING ALI Information Must Be Compteted. Permft Can Be Denied Due To Incomptete Information - -��
'
Existing Proposed Required by Zoning °��
�� w�"m�ou�m� ��
Building Department
' �- - —^ 7 `
Lo Size > \ -_- - .L_ __ / ~
�`
' l ` - l/ ' --- ---
. � /� � _�� v
Setbacks Front , / i | [ |
Side Ld i !
zz -•. ,
Rear L_J
Building Height [
Bldg. Square Footage F F F--1 r---1 ^__-~ ` / � . _~ . '. .
Open Space Footage F-7 ) % | | [ �
p~~="^~"�&,�� , .A i .__ .__� �---�
parking) I [ 1
#of Parking Spaces , ' ^ ' _--�
|
Fill: | ' / |
(volume &u*m�n / || i � --- '
A. Has a Specia Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Q YES 0
. l '
IF YES date issued: /
IF YES: Was the permit recorded at the Registry of Deeds?
NO ^~~� DONTKNOVY �� YES �~�
�� �� ��
IF YES: enter Book / Pagel | and/or Document # )
' L � | _____-__-_-_-
�� ��
B. Does the site contain a brook, body of water or*ed �� ands/ NO «_~� DON7KNOYY v�� YES v��
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained «-� Da�e|ssued' -- -
»�� »�� , 'L________--
��
C. Do any �gnsexist on the pnoper� �� property? YES «�� NO x��
IF YES, descnbe size, type and tocation:
D. Are there any pro changes to ar additions of signs intended for the property? YES 0 NO 0
IF ¥ES, describe size, type and Location: |
_ ___
E. WIH the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre orioit part ufo common plan
that will disturb over 1acre? YESK � NO &/l
"�^ ~��
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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,3�F ty of Northampton
_. B ilding Department s 11;,....1,11 "
212 Main Street s 1 _ � ''Ifi -
{ Q ZO I I Room 100 ,�,
No hampton, MA 01060
a . orsuI viNm r • P -.
;: .87 -1240 Fax 413- 587 -1272
NORT+1AMPT• MA O1Ori s ,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
( /' 1.1 Property Address:
\, ' •91tR c-c. f\r .• r - Map °Lot Unit
„ , c Zone Overlay District
t ` \ M I isn 1 / D\t O 0 Ekrt St District CB District Q J
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print Current M fling A dress:
�Z9 5
Telephone
Signature
3
2.2 Authorized Agent:
L f • .4* tTA-t , i2 - PO n) \ < N/ ' -T.
Name (Print Current Mailing Address:
!1.'!,i►'... ___q/ -i 6
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS A D 0 'I�. j.∎ 1--) A L
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building c ()I) O (a) Building Permit Fee
2. Electrical 0 / /'1 (b) Estimated Total Cost of
lJ Construction from (6)
3. Plumbing /' O O Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection �^
6. Total= (1 +2 +3 +4 +5) V' VZI 0 Check Number 79
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
Building CommissionerI1nspectorof Buildings Date
File # BP -2011 -1058 ' ,
APPLICANT /CONTACT PERSON SCHIFFER ELYENA Q,�1 =`1
ADDRESS/PHONE 1 KARY ST NORTHAMPTON (914) 629 -2764 0 ��� JJJJJJ 104,116)1
li
PROPERTY LOCATION 1 KARY ST
MAP 32C PARCEL 206 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out � / �
Fee Paid i(
Typeof Construction: REMODEL KITCHEN
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION PRESENTED:
17 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
/6 6/i
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
1 KARY ST BP-2011-1058
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 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: renovation BUILDING PERMIT
Permit# BP- 2011 -1058
Project # JS- 2011- 001702
Est. Cost: $8000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 3702.60 Owner: SCHIFFER ELYENA
Zoning: URC(100)/ Applicant: SCHIFFER ELYENA
AT: 1 KARY ST
Applicant Address: Phone: Insurance:
1 KARY ST (914) 629 -2764 ()
NORTHAMPTONMAO1060 ISSUED ON:6/17/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN
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 6/17/2011 0:00:00 $40.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner