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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 1 08.3.4 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;-ta act as their owff`constiui tion 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 your), 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
�ermits 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
m de
r7 +-� L Q Y � +dnderstand the above.
.(Home owner 1 esident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued tome.
Date
Address of work
location S•t-
E
The Commonwealth of Massachusetts
Department of Industrial Accidents .
Office of Investigations
600 Washinpon Street
Boston,MA 02111
,v www massgov/dig
-Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LegibIy
Name(Business/orgmn n ion/individual):.
Address: / d4 21
City/State/Zip: 1`-I)CLO�l 71 216(p at. Phone.#: (�13) 3 /-300 tl
Are you an employer?.Check the appropriate'box:
-Type of project(required):.
I.❑ I am a employer with 4.- El I am a general contractor and I
employees(fall and/or part time).
s have hired the sub-contractors 6. ❑New construction,
2-Q I am a'sole proprietor or partner- listed on-the.attached sheet. 7. E].Remodeling
ship and have nQ e�loyees .. These sub-contractors have. .8. ❑Deiaolidon
working for-me is airy capacityIo-yecs-and have worriers' 9 _ ii addition
[No workers eomg,insun-ance _ coup--insurance. _ ....-
required] 5. We are a corporation and its 10.0 Electncal repairs or additions
1'3. I am a homeowner doing all work officers havexercised their 11.0 Plumbing repairs or additions
myself[No workers'comp. right tifexemption Per MGL 12:0.Roofrepairs
insurance required.]t c. 152,§1(4j;and'we have no
employees:[No workers'. 13.0 Other
comp.insurance required.].
'Any appliraat-that checks box#I-st,also fiR outthe section below!showing t Xir.V0 leers'-compensation policy mformadmL
t Homeowners ovho subirut this affdavit:indi=ting they=doing an work and then bae outside contract=must submit a new.affidavit mdirntmg such.
:Contactors that check this box nmst.attaehed as aMba aal sbed.sbcy&g then==of the sub-con=ctors and state whettier-or notthosecmdtfes have
employees. If the sub—=radars have employees,d ey must provide Miter workers'comp..po1icy nnmber.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: .
Policy#or.Self-ins.Lic.#: Expiration Date:
Job Site Address: City/Stafe/Zip:
Attach a copy of the workers';compensation policy declaration ire showin the h number.and u�ation date.
Faihire.to•secure coverage:as required under.Section'25A:ofMCrI c '152 cirri lead to die imposition of criminal penalties of a
fine up to$1,500.00 and/or one.-year.impnsonment;•as well.as civil.penalties is the form of a STOP Fl? and--a flne
of up to$250 00 a day against the violator. Be advised that a copy of this statement may be forwarded.to this Office of;
— > -.._ _.
Tnvestitaations ofthe DIA for izisurance'coveraze verification
I do ereb_certr
under andnalti'es o.
----�' — �' P_ fP 7m3'thafthe irfformadonprovu edssbctve rstrne_audrarrect'
Phone#:
Official irse only. Do not write in this area,to be completed by cry or Town official
City or Town: NrmltUcense#
Issuing Authority(circle one):
J.Board of Health 2.Building Department 3.Cit r/Town Clerk .4-Electrical Inspector 5.Plumbing Inspector
6.Other
IContact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
N., an b -, r '� wi Not Applicable ❑
9,Rea Wered.k&iW6nk0i�emiktoif 6td1" a,S -5 .� . E.- A , , _ h, �a .
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...... ❑
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
orthampton Ordinances,State Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signatur
SECTION 5-DESCRIPTION'.OF PROPOSED'WORK'(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ® Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[E31 Other[a
Brief Description of Proposed, / /1^�
Work: ZIr? /!T/�'1 IJC( AAA Ab ded
a�i�, two
Alteration of existing bedroom Yes No Adding new bedroom Yes V No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -She
sa.1f blew hdus"rtd r alddi + n�o-'exist�r a n srnci r oilrll l �!the'Mtow rta:
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 AUT.HOR17ATION-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 authorized by this building permit application.
Signature of Owner Date
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.
Sinned under the pains and penalties of perjury.
Print Name !!
Si o er/Agent Date
,
, . .
.-
`
? �
�
'~*v
Section 4 ZONING Alt 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
. /
'
' Frontage /
Setbacks Front
Rear
Building Height
Bldg.Square Footage 011/0
Open Space Footage %
(Lot area minus bldg&paved 7
(volume&Location
'
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
�� ��
NO �_��� 03N7 VY �_�KNOW YES v��
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0
IF YES: enter Book 9 Pageand/or Document#
B. Does the site contain a brook, body of water orwetlands? NO DONT KNOW 0 YES »~�
IF YES, has a permit been or need tobe obtained from the Conservation Commission?
Needs tobeobtained Obtained »~~� Date Issued:
['-----------
' || l
C. Do any signs exist on the property? YES 0 NO JIM
|F YES, describe size, type and iocation' | |
'
D. Are there any proposed changes to or additions of signs intended for the property? YES �~� NO
v��
|F YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation, ur filling)over 1 acre oriuit part ufa common plan
that will disturb over 1acre? YEG ���� NO K��
��
IF YES,{hen o Northampton Storm Water Management Permit from the DPW io required.
City of Northampton
Building Department _ yr� "
GOB 'C' ��
212 Main Street
Room 100
\` Northampton, MA 01060
on 413-587-1240 Fax 413-587-1272
ck ION 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
Map Lot Unit
r
fo�,�n L`f' �15 01060j Zone Overtax District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
ciaud In-P,
2.1 Owner of Record: , a
Name(Print) Current Mailing Address:
Yc,J Telephone
2.2 Authorized Aoent: 7
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed b permit applicant
1. Building -A V (a)Building Permit Fee
2. Electrical
• � (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) D
5. Fire Protection
6. Total=(1 +2+3+4+5) d Check Number
This Section For Officlal Use Only'
Building Permit Number:
TDated:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2011-0*996 kV
APPLICANT/CONTACT PERSON WITMER CLAtJDINE `r06 -
ADDRESS/PHONE 171 NORTH MAIN ST FLORENCE (413)341-3004 O Y 31�
PROPERTY LOCATION 171 NORTH MAIN ST
P�
MAP 16D PARCEL 01 8 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE CC
�
ZONING FORM FILLED OUT
n�7
Fee Paid l
Building Permit Filled out l 't
Fee Paid
Typeof Construction:_DOWNSIZE 2ND FLR DECK 20 TO 9'&REPLACE 1 ST FLR SLAB W/WOOD DECK 6
New Construction I�
Non Structural interior renovations V
Addition to Existing
Accessory Structure
Building Plans Included:
c
Owner/Statement or License
3 sets of Plans/Plot Plan ` U
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved Additional permits required(see below) QQ
PLANNING BOARD PERMIT REQUIRED UNDER:§ V� ,
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
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.