29-327 V
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
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The State of Massachusetts allows the homeowner the right under 780CM1R 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 hour) 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 occupancv
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 bet their required
inspections. Failure of the 111di V idjlal 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, T a—*-g tQ J S 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. y
Date
Address of work
location
The Co.n1n oil wea%th O'Mr use:.s
Dean ar nment of 1'T adzisr.ial AccidenrS
= 01 ce of Ir.resti,aeons
µ 600 IT'wshin ton Street
Boston, 2114 02111
www.mass.gov/dia
V,,'orkers' Compensation Insurance -JUEdavit: Builders/Coatractors,''EIectricians/Ph ;ambers
Applicant Information Please Pripit Legibly
?Van1Z (Businessi(Dr;an:ratioa'Individual): ffo4d _
AddresSz:
Citvv/StatciZip.- Phone r:
Are you an employer?Check the appropriate box: Type of project(required):
I am a employer with ❑4. I am a general contractor and I 6 E]-'New Construction
1.❑
employees (fu have hied he sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet. 7. F7 Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any ry ca aci employees and have workers' ro
P 9. ❑Building addition
[No workers' comp. insurance comp. insurance.- 10. Electrical repairs or additions
required_] 5. ❑ We are a corporation and its ❑ P"
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself o workers' comp. right of exemption per MGL ,, ❑
[N 1_ Roof repairs
insurance required.] C. 1�2, §l(T), and we have no
employees. [No workers' 1-'.7 Other
comp. insurance required.]
*Any applicant that checks box=l must also 5ll out the section below showin.-their workers'compensation policy irfotT^ation-
Homeowne:s who submit this affidavit indicating they are doing all work and then hire outside contactors mist submit a new ai±ndavit indicating such.
,Contractors that check this box must artached an additional sheet showing the name of the sub-contactors and stare whether or not those entities hive
employees. If the sub-contactors have--=lovees,they must provide their workers'comp.policy number.
lam an employer that isprovid.n�workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name- _
Policy='or Self-ice.Lic. T: 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigariors of the DL?for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct-
�natur° GYt,�W , Cfif t 5 Date:�Z Z 3 D
Phone ,
0flicfal use 01711,'. Do not write in this area,to be completed by city or town ojjiciaL
City or Town: PermitLicense=`
Issuin?Authority(circle one):
1.Beard of Health 2.Building Department 3. City/Town Clerk 4'.Electrical Inspector S. Plumbing Inspector
6. Other �I
i Co::tact Person: Phone T:
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ScC T ION 2 -CONSTRUCTION SERVICES I r_ i
E.' Licensed Construction Suoer/;sor. Not Applicable ❑
Name of License Holder:
License Number
aacress Expiration Date
Signature Telephone
I.Reaiste:red Home ImDravemertt Contractor Not Applicable ❑
:omoanv Name Registration Number
.ddress Expiration Date
Telephone
ECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G.L.c. 152,
'orkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit.
fined Affidavit Attached Yes....... ❑ No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied DweIlinQs 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 1083.5.1.
Definition of Homeowner:Peron(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 Ofrar cial,that he/she shall be
responsible for all such work performed under the building permit.
As actin-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 annd,State Qof,Massachusetts General Laws Annotated.
omeowner Signature
SECTION 5-DESCrtPTIZN OE PROPOSED WO=K(check all aDolicabie)
I
I New House Addition Replacement Windows Alteration(s) C Roofing
Or Doors D
Accessory Bldg. Demolition I—I New Signs Decks [!F7 Siding [p] Other[!Z�]
Brief Desonption of Proposed
Work: 'a Pl/ t e r- S t o y Q l iJ
Aiteration of existing bedroom Yes No Adding new bedroom Yes No
At ached Narative Renovating unfinished basement Yes No
Plans Attached Roil -Sheet
sa. If Hew hound and ar addition to exisfing h&using;
�
*
Section 4. ZONING ALL Information Must Be Completed. Permit Can Be Denied Due To incomplete info a
Exiszinz Proposed Required by Zonina
EReqd byZ
This column to be filled in bv
uilding_-Department
Lot Size
Setbacks Front
Rear
B Building Heigh
uildin.-Height
Op:eneSpace Foota.ge %
(Lot area minus bIdg&paved
uarkinin
aces
of Parkina Sp
(volume&Location)
A. Has aSpeciai Permit/Yariance/Finding ever been issued for/on the site?
���~� v-� x��
NO DON7KNOYY �_� YES �~�
IF YES, date issued:-
IF YES: Was the permit recorded at the Registry of Deeds?
��
NO �� DUn7 nnuKNOW 'ES
_
IF YES: enter Book ' � Puge^ and/or Document#� �
B. Does the site contain a brook, body of water orwetlands? NO 0 DONTKNOYY 0 YES
IF YES, has permit been or need to be obtained from the Conservation Commission?
/------------`
Needs tobeobtaned �-\ Obtained y—\ Datehsued� �
' m_� ' \~� '
C. Do any signsexistonthepnoperty? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions ofsigns intended for the property? YES 0 NO y=\
IF YES, describe size' type and location: �
E. Will the construction activity disturb(clearing,grading, excavation, or filling)over 1 acre orisk part ofa common pisn
that will disturb over Iacre? YES � } NO � )
`�/ `_�
Sfa—rm Wit-e�-Min—agemen-f Permit from the DPW is required.
IF YES, then a Ncrth�—m&fon
Department use only
--City of Northampton Status of permit.
0tiling Department Curb Cut/DrtvewayP-errnit
212 Main Street Sewer/Septic Availability
f Room 100 Water/WelEAvalability
2 3 200$Northampton, M, 01060 Two Sets of Structural Plans
phone 413-587-1X40 Fax 413-587-1272 PJot/Site Plans
-;5
!
Other Specify
t APSP JCA T ION 7d G°dWkRuCT;-ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
rSECTION 1 -SITE INFORMATION erty Addrepss: This section to be campleted by office
q c l' b A o( Map Lot Unit
0J?e jvc (i yl) /I SS Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
C) 9 C_ ga(9()0X h je.
Name(Print)/ r /� e Currer�f tY1 n�Aedd�s�s:` m A S S
Q N t"t �-- �� !y /-I U L f .J� Telephone
Signature 59 J`
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-'ESTIMATED CONSTRUCTION COSTS
Item . Estimated Cost(Dollars)to be 0mciai Use Only
S f0V L� completed by permit applicant
1. Building (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 I ,
6. Total=(1 +2+3+4+5) I Check Number
This Section For Official Use Only
Building Permit Number issue
...Issued:
Signature:
(3uilding,Commfssione�/lnspecto�or w amgs Date
40 "`"" BP-2008-1058
GIs#: COMMONWEALTH OF MASSACHUSETTS
,; N V4*7 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-2008-1058
Project# JS-2008-001566
Est. Cost: $2687.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10497.96 Owner: NAULT RONALD J&JUDITH A
Zoning. URA Applicant: NAULT RONALD J & JUDITH A
AT: 308 ACREBROOK DR
Applicant Address: Phone: Insurance:
308 ACREBROOK DR (413) 585-8714 (�
FLORENCEMA01062 ISSUED ON:512312008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL PELLET STOVE
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 5/23/2008 0:00:00 $25.00MO
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo