25C-199 HOME OWNER EXEMPTION tiCKNOWLEDGEMENT
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
inspewor vanous ages,which in It cYerfouirdatinnrf#uotiugs(before ba�l�f�ll),
sonotube holes (before your), a rough building inspection (before work is
concealed), insulation inspection (if reduired)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
uni the worms canfie insi
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
h understand the above.
.(Home owner/resident's signature requesting exemption)
I will ca11 fo schedule 9I require ui mg insecaions necessary for the building permit
issued to me.
Date
Address of work
location
The Commonwealth of Massachusetts
Department of Industrial Accidents '
Office bfInvestigadons
600 Washinagton Street
Boston, MA 02111
4 `
-= = www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers
Applicant Information Please Print Leeibly
Name(Business/Organizati orAndMdual): _
Address: .4,? ��a� 64"
City/State/Zip: 0A.O o 7 Phone
FAre you an employer?Check the ap ropriate box: Type of project(required):
i-❑ I am a employer with 4. E] I am a general contractor and 1
6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.% I am a sole proprietor orpartner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. F-1 Demolition
working for me in any capacity. employees and have workers' 9 F-1 Building addition
[No workers'comp.insurance comp. insurance.:
required.] 5. [] We are a corporation and its 10.F-1 Electrical.repairs or additions
3.❑ I am a homeowner-doing-all—wank— -- - ---- officers have exercised their_ 11. Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12 it Roof repairs .
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
"Any applicant that checks box#1 must also flI out the section below showing their workers-'compensation policy information.
t Homeowner 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 sheet showing the name of the sub-contractors and state whether or not those entities have
employee's. If the sub-contractors have employees;they must provide their workers'comp.policy number.
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/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-$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 advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains dpetalties fper,jury that the information provided above is true and correct.
Signature: Date: &hi/,
i
Phone#:
7�. y. Do not write in this area, to be completed by city or town offrclal
Perr-nit/License#
rity(circle one):
- �.Board of-Health?—;ufldhw,-D-epar-tment 3.City/Town Clerk--4._ cal Ins ector S Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:— e!5 D 9'74 53
License Number
Address Expiration D e
6t7
Signature Telephone
9:.Re"istered.Etame[ixi°"civemeiit,Caititacfor"« .,,.; Not Applicable ❑
/ /46a2-
Companv Name Registration Number
/1,9/ZI
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...... ❑
liv
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
completro"fthe-work for-which-this-permi�is-i-ssued.----------- -________
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 f Massachusetts General-Laws Annotated.
Homeowner Signature zr" - �
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House F-1 Addition F-� Replacement Windows Alteration(s) Roofing
Or Doors D
Accessory Bldg. ❑ Demolition � New Siyi:s [C] Ducks [C] Siding[Q] Other[C]
Brief Description of Proposed 5 �¢ I(� 1 �. 6e,—LOC
Work:
Alteration of existing bedroom Yes_P�No Adding new bedroom Yes �_No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa klf a o� ne i r [ed a acl.ti> axaff au ent> - Q r lef i 6*(kvr� t t:
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:AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, c� as Owner of the subject
prop
hereby authorize J6 V
to act on my behalf, in all mattet relative to work authorized by this building permit application.
Signature of Owner Date Q
ply y as Owner/Authorized
Agent h reby de re that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed and r the pains and penalties of perjury.
Print NarVe �--
Signature I Owner/Agent Date
ti
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 __.
—
Rear
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 0 DONT KNOW YES 0
IF YES, date issued:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book i Page _' and/or Document#
AX
B. Does the site contain a brook, body of water or wetlands? NO Xj 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 , 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 NO
IF YES, describe size, type and location
E. 'Kill the construction activity disturb(clearing,grading cavation, 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.
f,
v
,ys d
I orthpmpton �
d tiOc g opartment
- --M Klein;Street
Room 100
JUN 2 ( J mpton_MA 01060 al farts
phone 413-587-1240 R x 413-587-1272 'I
AF*P-LICATION-TaCOMSTRtlCT;ACTER;'REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ,_7
SECTION 1 -StTE INFORMATION-
This section to be completed by office
1.1 Property Address:
15-3 Map Lot Unit
Zone '0vertay District
•.r=WSt,?District CB District
SECTION 2-PROPERTY OWNERSHIP1At)THORIZED AGENT
2.1 Owner of Record:
�_ S-3 ljC�)e-rj.t S% Ily rt°i r►1���v
Name(Print) Current Mailing Address:
Telephone
ig lure Jv�"0�
2.2 Authorized Aaent:
ol5v
Name(Print) Current Mailing Address:
Z_Z'04J
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars,)-to Official Use Only
completed by ermit applicant
1. Building �-a (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=0 +2+3+4+5)
Check Number
e
-This-Sectian.-For Official Use Oril
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2009-1100
GIS#: COMMONWEALTH OF MASSACHUSETTS
map g �;� T,� 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-2009-1100
Project# JS-2009-001596
Est.Cost: $5000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WAYNE BOISVERT 146292
Lot Size(sq. ft.): 8537.76 Owner: MAZUR JOHN A&JAMES A LABATO
Zoning:URC(100)/ Applicant. WAYNE BOISVERT
AT. 53 NORTH ST
Applicant Address: Phone: Insurance:
48 CARILLON CIR (413) 539-8003
EASTHAMPTONMA01027 ISSUED ON.612912009 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE PARTIAL ROOF
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:
FeeTyDe• Date Paid: Amount:
Building 6/29/2009 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
53 NORTH ST BP-2009-1100
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C- 199 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: BUILDING PERMIT
Permit# BP-2009-1100
Proiect# JS-2009-001596
Est.Cost: $5000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin WAYNE BOISVERT 146292
Lot Size(sq. ft.): 8537.76 Owner: MAZUR JOHN A&JAMES A_LABATO
zoning:tJRC 11,0 Applicant: WAYNE BOISVERT
Applicant Address: Phone: Insurance:
48 CARILLON CIR (413)539-8003
EASTHAMPTONMA01027 ISSUED ON.612912009 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE PARTIAL ROOF
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:t /AC- 7'7'G77
THIS PERMIT MAY BE REVOKED BY THE CITY 9V NORTHAMPTON UPON VIOLATJQN OF
ANY OF ITS RULES AND REGULATI
Certificate of Occupancy Si nature:
Fee'Cype: Date Paicr Amount:
Building 6/2912009 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo