38D-042 (3) . _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 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
permits 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 ofMassachusetts
•■■■AI■ Amo 1 ■ Department of Industrial Accidents
Office of Investigations .
600 Washington Street
Boston, MA 02111
www.mass.gov/dia ' ....-
.-.
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
plicant Information - Please Print L .. .blv • ''
Name pusinesi/Organiimion/Individual): 1 C lia(Z-r) 0 itAACITle - ...•
• - Address: ir7 <6 liVit Mitie-- 4: ( _ •
. - • _
,,
City/State/Zip: oodb Ut atar Phone.#: 1/ 3- -c - 6f
Are ou an employer?.Check — thi appropriate box: • Type of pi (required): l
1. ill' am a employer with 4. 0 I am a general contractor and I
6. 0 New coistruCticm
employees (full and/or part-time).* have hired the sub-coniractors
listed on theattached sheet 7• D Remodeling
2. 0 I ain a Sole proprietor or partner-
These sub-contractors have
• ship and haven°. employees •8. 0 Demolition
ertmloyeesand have workers' - • .. -. •
working for me in any capa.city. 9. 0 Build* additidn
_ comp.ixistuance.;_.: _
[IsTo workem ' comp. insurance
10.0 Electrical repairs or additions
required.} - - 5. 0 We are a corporation and its
3. 0 I am a homeowner doing all work officers havexercised their . 11.o Plumbing repairs or additions
-I.
myself [No workers' comp. right of exemption per MGL r-1.:, - -
au .K.00r repairs . -
insurance required.) t ' c. 152, § 1(4), and we have no
employees. [No workers' 13zpOther Lici
comp. insurance reqtifred.1 • .
*Any applicant -that checks box #I- must also fill out the section below showing theirworkers' convensation policy information:
t Homeownera who submit this affidaVit indicating they am doing an work and then hire outside contractors must submit anew affidavit indicating such.
:Contactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether-or notthose entities have
employees. If the sub-contractors brie employees; they must provide their worions' comp. policy nmnber. . .
I am an employer that is providing workers' compensation insurance for my einplOyees. Below is the poliCyanil job site
information.
Insurance Company Name: ehapki_.ticit,,,,ei( :.., . . -
Policy # or Self-ins. Lic. #: to k Lt. 6 -- oc3 )-. Expiration Date: - .3 ( /90/5
e
Job Site Address: ."5 • - `:-(2.) . t City' /Sta&Zip - L I tkjeIts fittt ; Oi 01,0 0
# i
Attach a copy of the workers' compensation policy declaration page•(showing the policy number and expiration date).
Failure to secure coverage as required 'Mid& Seetiiiii25A - C. 152 can lead to the imposition Of Ciiniinal penalties of a
fine up to S1,500.00 an.d/or one-year imprisonm*, as well as civil penalties in the form of a STOP WOIZICORDER. and a fine
of up to $250 00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
IfiCeitons Of th for insurance C:ciiieiiie 'iGiC,Iiiiiii. -
.17IO her* ea0 -, i' ";:,: ei .., , , ales ofieijarythat the infonnattonproviderInhave _ op..ect.____
Signature: /
Signature: i , t - 43 . /./aLt4.0..,...... - - / ... Date 1
Phone #: ( 1(3) \ ::fira . - - • •
Official use only. Do not write in this area, to be Completed by city Or town officiaL
City or Town:
Permit/License #
Issuing Authority (circle one):
.- ,...., .... .
.1. BOard of Health 2. Building Department 3. City/Town Clerk 4. Electrical ,Iii.spector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #: f- . . •
It
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: n Ap
Not Applicable ID
Name of License Holder : OSLC -∎ 0 QkAA.A ' C3 15 % 4 /FS -
License Nu .
5 ,� t j (-. Qt �3 �J jtici
A s\ Expiration Date
Y ri J ea i/�/e"stC'� 7� J - L' / CD '-1
Sig ture Telephone
latettlitel* Etnifin IMe ii eme�i ='I + %t l tor; la ' : ' TaafEak Not Applicable ❑
Q Ott, s,xt; z /(...- ' /(o SW/
Company Nakne Registration Number
7 ' 1. t` 7) / /dn,
Address Expiration ate
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 ❑
ome.O a
11. i= . m
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 buildine 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
y
SECTION. 5- DESCRIPTION! OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement_ Wipdpws Alteration(s) EI Roofing El
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [D Siding [0] Other [D]
Brief Descriptis of Proposes , . - �. �( __A3
Work: 4_4. . 3 k _ _ , , , , —Tens • ( , k___., . lit S , r - j'S
� 0
Alteration of existing bedroom Yes i.�NO Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes
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
1 , at A - t h, , c; L . Ke' � Or as Owner of the subject
property
hereby authorize Ct=t ) N CA_ AA "
to act on my behalf, in all m tters relative o work authorized by this building permit application.
-. ) . /4 / 1-- 0 as Q /L /6//
SignaYdre of Owner / Date
1, Ir "I` ' .1Ik _ , , , ell-Cs , as Owner uthorized
Agent h reby declare that the statements and information on the foregoing application are true and accurate, to the best of ge
and belief.
Sig • under the pains - • 'enalties of perjury.
r ill VkiAe-D liA,,,,,,,....
Pri e,_
r �. a ( t, 1s)_
Signat b re of Owner /Agent Date
k a
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
I
Setbacks Front j r I I
Side L: R:r L: a R } ,`
Rear 1
Building Height t 1 !
Bldg. Square Footage El= = % E= = I
Open Space Footage %
(Lot area minus bldg & paved E ! a `m
parking)
# of Parking Space # _
Fill: 1 l ._. ..- i
(volume & Location) ' Li
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 i Page[ and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q 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 0 , Date Issued: ,
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location: 1
E. WiII 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 Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
C � , C of Northampton
0 2 no B 'Iding Department , n �
E -----------1
EC .12 Main Street m " g -
Room 100
p� PT. O F Bud DING U'P : m pton, MA 01060 m
NORTH one 41 587 -1240 Fax 413- 587 -1272 ° -
9
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:
Map Lot " Unit
Zone �' OverlayDistrict
Elm - St District : ' CB District 'r
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
12____
e
Name (Print Curr ent Mailing Address _
U' 2*-"/".----- Telephone
Signatu
2.2 Authorized Agent:
ni,a c� y" ? tntck I2 C td4-
Name P _ Current Mailing Address:
W O) r u 919 = 10
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 7tO (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 t 3 , �
6. Total = (1 + 2 + 3 + 4 + 5) �(p Check Number �`�' lJ ' J ..
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
40IIARLOW AVE BP- 2013 -0640
GIS COMMONWEALTH OF MASSACHUSETTS
Map: Block: 38D - 042 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cat,-tory: window replaced BUILDING PERMIT
Pet t # BP- 2013 -0640
Pro .ct # JS- 2013- 001042
Est. Cost: $7650.00
Fee $35.00 PERMISSION IS HEREBY GRANTED TO:
Coast. Class: Contractor: License:
Use Group: RICHARD PALMISANO 89485
Lot :;ize(sq.ft.): 5706.36 Owner: PARENTE ANNE
Zo . _.g: URB(100)/ Applicant: RICHARD PALMISANO
AT: 40 HARLOW AVE
i 'leant Address: Phone: Insurance:
87 `) HATTUCK RD (413) 549 -6824 WC
HADLEYMAO ISSUED ON:12/10/2012 0:00:00
; PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
PC T THIS CARD SO IT IS VISIBLE FROM THE STREET
Ins
, c tor of Plumbing Inspector of Wiring D.P.W. Building Inspector
Un rground: Service: Meter:
Footings:
Ro 'h: Rough: House # Foundation:
Driveway Final:
Fir Final:
Rough Frame:
Ga .: Fire Department Fireplace /Chimney:
Rol: ;I:: Oil: Insulation:
Fir .. Smoke: Final:
Ti. ; S PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
Ars ':' OF ITS RULES AND REGULATIONS.
CP tificate of Occupancy Signature:
Fe, Fvpe: Date Paid: Amount:
Bt: 'ing 12/10/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner