32C-230 (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; - 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 occunancv
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
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.
Date
Address of work
location
` T
. The Commonwealth of Massachusetts
--- Department of Industrial Accidents - ,. ,
P: _7 = Office of Investigations •
• . _ " "1�
.v = f= y 600 Washington Street
f Boston, M 02111
:�``� . www.mass.gov/dia -
• -Workers' Compensation Insurance Affidavit:. Builders/Contractors/Electricians/Plumbers -
Applicant Information • Please Print LegiibIv
Name ness/Or on/Individual ' Z- C:i4; c -'• �7 e .- {,•,r *' t..1 c -«' :
• Address: ,C 4 �y I, y /2 :Z)/ ,1,- c I .%/-/
City /State/Zip: Q''/' c) -Z- . Phone. #: 4 l! 7 Z ' 6 7✓ <J
Are you an employer? Check the appropriate'bor T e of i o'ect r .
4.. I am a general contractor and I YP P ] (eQ 'ed):
1. ❑ I am a employer with ❑ g 6 ❑ co
employees (full and/or part-time).* have hired the silt- contractors
2_0 I ani a sole proprietor or partner- listed on- the:attached sheet. 7. ❑.Remodeling
• ship and. have no eloyees .. These sub - contractors have .8. 0 Demolition • . .
.
working forme in any t3' tvs eilo_ye and. workers'
lli " ti
[No workers-' comp insurance - _ r� turanc • #:_ .. II a c ....
5. a ar a c o oration and its 10.0 Electrical repairs or additions •
requited:] rp
3. ❑ I am a homeowner doing all work officers have xercised their 11.0 Phunbmg repairs or additions
myself [No workers' comp. ri of exemption per MGL 12: Roof airs
insurance required.] t • c: 152, §1(4); and we have no . P .
. . employees: fNo workers' - 11[] Other
Comp- insurance required}.
*Any applicant that checks box fa must .also ffi out the section belo'Wsbowiag the rworioas'..compensation policy Wfonmation:
• t Homeowners who submit thin affidavit:indicating they are domgaf work and then hire outside contractors rmst submit a new affidavit indicating such.
( contractors that check this box must attached an additional sheet showing the name of the sub contpctors and stater whether have •
employees. If the sub- rnntractors have employees, they must provide their workers' comp- Policynumb •
I aft: an employer that is providing workers' compensation insurance for my employees Below is thepolicy and job site
-information. •
Insurance Company Name: -
•
Policy # or Self-ins. Lic. #: Expiration Date: .
Job Site Address: City/State/Zip:' r -
-Attach a copy of the workers' compensation policy declaration page - (showing the policy number a expiration date).
• Failure to secure coverage:as required under Sectivn'25A'of1VIGL c.' 152 can lead to the imposition of Criminal penalties of a
fine up to 51,500.00 and/or one -year imprisonment,' as well as civil .Penalties in the form of a STOP WORK -ORDER and a fine
• of up to 5250.00 a day against the violator Be advised that a copy of this statement maybe forwa ded the Office of .
rn rtiA iihon`s oftti DIA for ins c verifi
I de hereb - certi un the o
y ,fy pains and penalties :ofperjury thafthe tnfornration providednbQVe , ,a
,��_aadrorrert
Si tnre: ` Da �.° �''/ �f
Phone #: C /- ( 7 . 'z--- .. - , . .. • .
Official use only Do not write in this area, to be completed by city or town official
. ` City or Town: .. '. Permit/License #
I Authority (circle one):
."1. Board of Health 2. Building Department 3. City/Town Clerk . 4. Electr-ical,Inspector 5. Plumbing Inspector
6.Other . r^ . .
Contact Person: Phone #:
SECTION 8 -- CONSTRUCTION SERVICES
8.1 Licensed Constructs ervisor: /�,/ Not Applicable ❑
Name of License Holder : .4 f /C (, /°.i s G», J 1 f C/ , '✓
License Number .if-i
Address Ex piration Date
..---4707116"--- 'f /, ? - 7J - i'i
Signa re Telephone
g ReaisteridMatn lmpro'iieri4iitta br ^... z. ,a kat . a -t : Not Applicable ❑
--� 4 4 "" 6 604; cA y ), 6. :~. ,L'/ / C 'O i z--
company Name Registration Number
d $ 4 .,,1 ‘.- /) ', ,t ✓J 7 2 7-z //z.- Address . / , , �- ' r Expiration Date
Telephone
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit ust be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buiidi permit.
Signed Affidavit Attached Yes No ❑
I .3 me: O wn e le ti
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) Er Roofing d
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E1 Siding [lam] Other [0]
Brief
Work: Description of P `. `// Z ew
‘die 70, J�z /y i i /
4Irtr ''t.T74 //
Alteration of existing � bedroom Yes p"No Adding new bedroom Yes - No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
ii! :if ife roeis iiii :tii . Iddlit i . iciiitrrq Trust ra:a ril a art titr :
a. Use of building : One Family Two Famil Other /�/ " /�
Y
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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, C' ,� ; �'l ` n-e \-k; n (30-- , as
Owner of the subject
property
hereby authorize
to act o •• behalf, in all matters relative to work auth rized by this building permit application. \„_‘..ci
Signature of Owner Date
/ f'
I ' , as Owner /Authorized
Agent hereby eclare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Si der the pains and penalties of perjury.
C 1/ J4 U -ic Ci4 : c'-' s r'
Print Name - r
C. it /1
Signature of Owner /Agent Date
/p`�
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 i ` J,.t ° 'lid
Building Department
I
Lot Size _ _ _ _ _ . « . , , . n� . ,�,..., <
Frontage ? ...
Setbacks Front v` a
Side L: ....... - . R. 1 L:` i R.' __ . ( ..
Rear I i
Building Height € 1 r =
Bldg. Square Footage I 1 r i % 1 n 1--1 I
Open Space Footage % _ ; - �..____...
(Lot area minus bldg & paved 1 ,._.
parking)
# of Parking Spaces
Fill:
(volume & Location)
it 1 i f
A. Has a Special Permit /Variance /Finding ever een issued for /on the site?
NO Q DONT KNOW 0 YES 0
. 1
IF YES, date issued:; I
IF YES: Was the permit recorded at the Registry f Deeds?
NO 0 DONT KNOW Q YES Q
IF YES: enter Book ' 1 Pagel 1 and /or Document #:
�
B. Does the site contain a brook, body of water or fiends? NO Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtain d from the Conservation Commission?
Needs to be obtained Q Obtaine Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions o 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, e vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES, then a Northampton Storm Water Management e it from the DPW is required.
413
�����'d
City of Northampton 4,.- Pe
I ; Building Department A _ - Y R .
2011 212 Main Street a $.,�
Room 100 :E�, R
Northampton, MA 01060 - - s k
;�vl► oF el�LoiNO rr tioi+i phone 413-587-1240 Fax 413 - 58 -
7 1272
w►oioeo rEC
uontwuAvra+. - 1 .
■
APPLICATION 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
J � li '1 l'o €. ,Map Lot - Unit
Zone Overlay Distr
Elm St:District ' CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
( *he - ; ne 4--: 1 � , ( Z c 4 (5J C, 5 -4-
Name (Print) t,� l \ Current Mailing Address:, 7) ' , V `ay A r \ q , t
1 I 4 ^�` 'crne„ \ 1Y1�`� Telephone 332.0 J + ►'\� lV /" �36b
Signature
2.2 Authorized Agent:
c
�,,,4 )4 ✓� C4: c,..* /� �: // >,� .w
Name (Print) Current Mailing Addr ss:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (D o liars) to be Official Use Only
completed by permit applicant
1. Building z � G ,. y (a) Building Permit Fee
7 '
t 2. Electrical (b) Estimated
Constru Total from Cost (6) of
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) fir'
5. Fire Protection
7
6. Total = (1 + 2 + 3 + 4 + 5) Check Number 19 L
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: //� C1 //
of Buildings Date
Building Commissioner /Inspector
25 HANCOCK ST BP- 2012 -0232
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 230 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Infill Sykylights BUILDING PERMIT
Permit # BP- 2012 -0232
Project # JS- 2012 - 000359
Est. Cost: $1900.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID CHICOINE
Lot Size(sq. ft.): 10280.16 Owner: Catherine Hinard
Zoning: URC Applicant: DAVID CHICOINE
AT: 25 HANCOCK ST
Applicant Address: Phone: Insurance:
16 EDGE HILL PLACE (413) 246 -7536
AM H E RSTMA01002 ISSUED ON: 9/9/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: infill two skylights for future solar
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 9/9/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner