32C-239 (2) 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 backfdl),
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
emits 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
Date
Address of work
location
..
...- , _ -
The Commonwealth of Alassachusetts
—,-- , Department of IndustriaLACcidents .
L.-47=-..-- ,
T 901.s=- ., ' Office of Investigations •
.= ; 600 Washington Street
it..., g #
t = ,,, Boston, MA 02111
f , - , - www.mass.gov/dia .
• _.,
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly '..
L\
Name (Businesi/Organization/Indivicion1): K A- t4 co v..s -. ' VA.!) IA / l 'Ai CI. /4 C 6) ci CU
.. .
Address: 13 ( r-e-„z-c-2 S.A.--- , -
tn° 1 -- (06 - 3
City/State/Zip: 1=- v
? Pon
1A.. he.#:
Are you an employer? Check the appropriate box: Type of project (required): I
1. 0 I am a employer with 4. D I am a general contractor and I
6. 0 New coiistmction
have hired the sub-contractors •
....loyees (full and/or part-time).*
listed on the sheet 7. ak Remodeling
2. IN I am a sole proprietor or partner-
These sub-contractors have
ship aid have no :iloyees 8. 0 Demblition
eroplo_yeesand have wOrkers' .
working for me m any capacity- 9: 0 Building aditiOn
[No workers' comp insurance
required.] 5. 0 We are a corporation and its 10.0 repairs or additions •
3. 0 I arn a homeowner doing all work officers have 4xercised teir . 11.0 Phinbing repairs or additions
- myself [No workers' comp. rieit Of exemption per MGL
12. Q Roof repairs
insurance requirecti t . 152, §1(4), and we have no ck
employees. [No workers' 13.X0ther .5 LQ-A-A 'R.o
. comp insurance reqUirerl.j.
*Any applicant that cheers box #I- must also fill out the section below shovring their compensation policy information_ -- • . •
t Homeowners who submit this affidaVitinclicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
1 Cozat•actnrs that chick this box must attached an additional sheet showing the name of the sub-contractors and state whether or notrhose entities have
employees If the sub-contraCtors have employees they must provide their workers cotnp. policy =ober.
I am an employer that is providing workers' compensation insurance for my einployees. Below is the policy andjob site
information. .
insurance Company Name: . • •
. •
. .
Policy # or Self-ins. Lic. #: Expiration Date: - . •
Job Site Address: - City/State/Zip:'
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as reqtiired inkier Sec 'of MGL 152 can lead to the ii*Osiiiii Of Ciiiiiinaj Pena ities of a
fine up to $1,500.00 and/or one-year implisonment, as well as civil penalties in the form of a STOP WORK-ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwardedtottie Office of
EnTeitiiitionS Ofthe COVeraii fiC:4 _
I do kereby_cenz:67 u der the , ains•and penalties ofPeprY that the information providettaboveisirue_aCorre
Si. .. tare: - ,:, / , ..., •gat - /0 1.10:
Phone 4: q ! 3 5 3 - iS 0 3 . : -
Official use only Do not write in this area, to be completed by city or town afficiaL
• . .
• .
City or Town: ". Permit/License #
.-----.._
-
Issuing Authority (circle one):
:1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical,Inpector 5. Plumbing Inspector
6. Other ,
Contact Person: Phone #:
r
SECTION 8 -- CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �! Not � Applicaable � ❑ j �r
Name of License Holder : KU '�1,.., ! " ` C O u % `° St 3 9 r
License Number
)? 1 f- s e -K X 0.6 k A'1 19, pi i j 10
Address Expire Dat
)/12J .� g37 s)
Signature Telephone
sl a istere C n tfstE�riarreruifsti l'ii eitt r i � ✓ n ,. iiit _. Not Applicable ❑
1< / l C_O v1 T'•I` U G. t 0' f O (g 70 U
Company Name Registration Number
Address t � Expir tion D e
ie- cL9 0.t 1 � ko v∎ Telephone 63
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (Mai. 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 Id' No ❑
,�'. QIIltl 9 A` e)G roil 1
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) I I Roofing ❑
Or Doors D
Accessory Bldg. El Demolition New Signs [0] Decks [Q Siding [❑] Other [RJ
Brief Description of Proposed �° l \ v
Work: S- pc_C�� µ LtV� ep 4'`n c �f jl,
Alteration of existing bedroom Yes V N o Adding new bedroom Yes �No
Attached Narrative Renovating unfinished basement Yes V No
Plans Attached Roll - Sheet
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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 1 ,� Ae �. , , as Owner of the subject
propert
hereby authorize 4,e/ Nc sPzi Q /(1
to act on my behalf, in all matters rela ve to work authorized by this building permit application.
Signature ner Date
1, - /j,, /, , - , as Owner /Authorized
Agent hereby 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 an pens ties of perjury.
Print Nam 1!� Lz
�
Signa : o Owner /Agent Date
i
r
1
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 i _ <
Frontage ` - f
Setbacks Front
Side L:: R :i ._. £ L:w. R:' 1 ..__._,_ —
Rear
Building Height r j ?
I ; .
Bldg. Square Footage r 1 [ 1 % r ----- 1 i ,
3 s
Open Space Footage
(Lot area minus bldg & paved __ „ J _ j
parking)
# of Parking Spaces L• __i W-„
Fill:
(volume & Location) €
A. Has a Special Permit /Variance /Findin ver been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:I i
IF YES: Was the permit recorded at the Re ' ry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Pagel and /or Document #'
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO e/
_1 .
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, ex vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
w
City of Northampton
Building Department _ i .
212 Main Street s�`
CC_ - 4 1010 Room 100 - - r���
Northampton, MA 01060 13
p hone 413 -587 -1 240 Fax 413- 587 -1272
°` - 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:
2/ C Map Lot Unit
Zone Overlay District
Est District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: /
M . A Name (P Current Mailing Address:
Telephone `` 3 .. 7 . /
Sy�ure
.2 Authorized Agent:
/<<., M c .t, 131 s- C ck. < 4k.
Name (Print) 1 r, Current Mailing Address:
//Ze./7 621`12' 413 3
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building d (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 �
6. Total= (1 +2 +3 +4 +5) Check Number p�5 Yy ' �
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
•
File # BP- 2011 -0311
APPLICANT /CONTACT PERSON KUEL MCQUAID
ADDRESS/PHONE 131 FERRY ST EASTHAMPTON (413) 537 -5063 ()
PROPERTY LOCATION 21 EASTERN AVE
MAP 32C PARCEL 239 001 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
Typeof Construction:_SHEETROCK LIVING ROOM CEILING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 051394
3 sets of Plans / Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
( 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
H // /4 / J
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.
.4041 ifiaN AN3 BP-2011-0311
GIs #: COMMONWEALTH OF MASSACHUSETTS
l/lap:Block: 32C - 239 °4 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- 2011 -0311
Project # JS- 2011- 000509
Est. Cost: $1000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KUEL MCQUAID 051394
Lot Size(sq. ft): 15812.28 Owner: HART JOAN M
Zoning: URC(100)/ Applicant: KUEL MCQUAID
AT: 21 EASTERN AVE
Applicant Address: Phone: Insurance:
131 FERRY ST (413) 537 -5063 ()
EASTHAMPTONMA01027 ISSUED ON:10/8/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:SHEETROCK LIVING ROOM CEILING
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 10/8/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner