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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 backfiil),
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 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
mad
understand the above.
me owner/residen s signature requests g exemption)
I will call to schedule all r quired building inspections necessary for the building permit
issued to me.
Date 2c�v
Address of work
location
The Cc nzmonwealth of Massachusetts
Department of Industrial Accidents
Q lice of Investigations
=' 600 Washington Street
Boston, MA 02111
www.inass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers
Applicant Information Please Print Leaiblv
Name (Business/Organizatiom'lndividual): —
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. El I am a general contractor and I
employees (full and/or part-time).*
have hired the sub-contractors 6. New construction
❑
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp.insurance:
required.]
5. [l We are a corporation and its 10.❑ Electrical repairs or additions
�.El I am a homeowner doing all work
officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no 131-1 Other
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional she et showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must p ovide their workers'comp.policy number.
I am an employer that is providing workers'coml ensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: —
Policy#or Self-ins. Lie. #: Expiration Date:
Job Site Address: City/State/Zip-
Attach a copy of the workers' compensation pol:cy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Sectio a 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be adv sed that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage of rification.
I do hereby certify under thepains andpenalties o fperjury that the information provided above is true and correct.
SiLynature: Date:
Phone#:
Official use only. Do not write u: this area,to I e completed by city or town official
Citv or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
1 ► `
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor.- Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MrG.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...... ❑
11. - Home OwnerEgempd6id
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 to you on er this permit.
The undersigned"homeo er"ce 'fes and as mes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, tate end cal Zo ing'La UandSt e of Massachusetts General Laws Annotated.
Homeowner Signature
1 i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition Re)lacement Windows Alteration(s) Roofing
Or )oors D
Accessory Bldg.. DDemo`itiQn ,'C Ne v Signs [0] Decks [0 Siding[0] Other[O]
wt< i
Brief Description of Propo ed 1
Work: rYLV1�S�1 trt SFIe� Cr�v�cl ire�l �n. `;.d�1 i1C�v ahe�( S�'Z� (U 7C 1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative R movating unfinished basement Yes _ No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing he using, complete the following:
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 regulat ons? Yes No.
I. Septic Tank City Sewer Private w all City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
[A as Owner of the subject
property ,rte
tt 1�LiJY�e W�
her AOfO e l.�-�\� 'n< < t1 n�
to half, i all m rs ti a to work authoriz d by this building it aZ11cation.
zoos
Signature wner Date
t(1 L' t as Owner/Authorized
Agent hereby declare that the statement and information or the foregoing application are true and accurate, to the be s—t o my knowledge
and belief.
Signed under the pains and penalties of perjury.
Jc'" l�-
rint
k Si nat
Date
of Owner/Agent
t r
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
Setbacks Front
Side L: .. ......... R . ,_.._. L �_.._. R _.._
yRear
Building Height �
_
Bldg.Square Footage %
Open Space Footage __„_ _._, %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location) ___..,. _.__.... ____.._, .__, .,,,,_.,_
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'f KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO JN DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
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,txcpvatiory, or filling)over 1 acre or is it part of a common plan
fix
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
-
Department use only
City of Northampton Status of Permit.:.
\; Building Departmeni Curb CUt/Di veway'Permit
212 Main Street Sevier/SeptcAvailab,trty
Room 100 Water/Well Availability',' '
vailability ' '
Northampton;
i s
File#BP-2009-0238
APPLICANT/CONTACT PERSON KINNER HELEN H&
ADDRESS/PHONE 38 OVERLOOK DR FLORENCE (413) 587-0327 Q
PROPERTY LOCATION 38 OVERLOOK DR
MAP 29 PARCEL 195 001 ZONE URA/WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out 04 404
Fee Paid Al it 41 WJ61-
Typeof Construction: REPLACE SHED W/10 X 16
New Construction
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FPLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IWALMATION 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
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relit ve a applicant's burden to comply with all zoning
requirements and obtain all required pernuts fi om Board of Health,Conservation Commission,Department
of public works and other applicable permit gr;inting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
01
38 OVERLOOK DR BP-2009-0238
GIs#: COMMONWEALTH OF MASSACHUSETTS
Ma p-.Block: 29- 195 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# B�-2009-0238
Project# JS-2009-000311
Est. Cost: $2983.00
Fee: $32.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor. License:
Use Group: Homeowner as Contractor
Lot Size(sa.ft.): 15463.80 Owner: KINNER HELEN H&
Zoning: URA/WSP Applicant: KINNER HELEN H &
A1: 38 UVECR- OOK DR
Applicant Address: Phone: Insurance:
38 OVERLOOK DR (413) 587-03270
FLORENCEMA01062 ISSUED ON:91912008 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE SHED W/10 X 16
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: p j{ i j
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
.. r
J
Certificate of Occu a cy Signature:
FeeType: Date Paid: Amount:
Building 9(9/2008 0:00:00 $32.001640
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo