17C-088 (2) i
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 w
location
The Commonwealth of Massachusetts
P _ Department of Industrial Accidents
' Office bf In vestigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: S
City/State/Zip: ' 26:��e_ 0 Phone#: (j' 5K— ?fo�)
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 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 S. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp. insurance.:
9. ❑Building addition
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
officers have exercised their
3.❑ I am a homeowner doing all work 11.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4), and we have no 13 ❑ Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#I 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 sheet showing the name of the sub-contractors and state whether or not those entities have
employees. 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
fne nP 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 ce r ai s and penalties ofperjury that the information provided above is true and correct.
Signature:
Date:
Phone#: ( �j— � COL-)
OffFcial 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 Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �( Not App1liicaabllee1,❑.(rQ�
Name of License Holder: F3
License N mber
Address Expiration Date
}'3 --!S`f —2c
Signature Telephone
9.Registered Hame.lm`rouemerit Coritracfior ;,. ., w. .' Not Applicable ❑
2
Company Name Registrdttion Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GL.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....... I!K No...... ❑
11. Ome;owner.. xem1 1011
The current exemption for"homeowners"was extended to include Owner-occupied Dwellin �(I) wo(2)families
and to allow such homeowner to engage an individual for hire who does not possess a li e,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 h lshresides 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,gar"a form acceptable to,the Building Official,that he/she shall be
responsible for all such work performed sunder t4 , uilding tdrmit,
As acting Construction Supervisor your pi-90KCe on the job site will be required from time to time,during and upon
completion of the work for which this pe it is issued.
Also be advised that with reference hapter 152(Workers'Compensation) and Chapter*153(Liability of Erhployers to
Employees for injuries not res ' g in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work f you under this permit. .
The undersigned"ho caner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordi ces, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
,r %.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) (VI Roofing ED
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding[0] Other[p]
Brief Description of Proposed R��.�� �t� f O(
Work: no,_
` r-1 Uyy1 {,
Alteration of existing bedroom Yes /Iqo-'�) Adding new bedroom Yes
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition.to eAsting'housing, 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 1 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basem or cellar floor below finished grade
k. Will buildi 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
I MuNea L. as Owner of the subject
property ff
hereby authorize 1--6 la11
to a on behalf, in all matters relative to work authorized by this building permit ap licatio .
Signature wner____ __ ___ --_---,--_--- _._ _ __ _____Date
CIQ 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.
Signed under the pains and penalties of perjury.
VA49V-
Print Name
Signature of Owner/ en Date
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
t_ �l1 ._ .,.,....,., ;
Lot Size ,.. ._.. ...._.. ,._,"____ , �_ ...,....,.."" .. .... .._......
Frontage _. .' ...._., . ..., __. .... ..,.. _,,, ..,
Setbacks Front
Side L:? .._, R.... L: _ ._f R:,-,--
..' _..__ .."
Rear
Building Height
fM
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
I
IF YES, date issued:`
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book Page: and/or Document#!
B. Does the site contain a brook, body of water or wetlands? NO 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 NO
IF YES, describe size, type and location: }
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will 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 0 NO 1
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use oily
G " Northampton
!tY of p Status a�errlt
Building Department Curb Cut Dnveay Perxntl M
\ A 212 Main Street SO—h5ept#c ara abtlty a77
Room 100 vua#eriNeJI A
- :,
`0hampton, MA 01060 Twa��isz�fstru CP1ans � ��
NNIII
hdn�413-587-140 Fix 413-587-1272 i iY�le�Jens '
�` OtJ�er Speafy 3
APPLI)CATION 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
10 tP Cffe$fiN Or S-r Map: Lot Unit
Fi Oggo')ce / 01062, Zone Overlay District
'Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
mayattj Conlea� ?e.Kl� 1M Gf u .�1C
N e Pr t) Current Mailing Address:
' Telephone
Sign tur
2.2 Au orized A e t:
RD aQQce
Name P t) Current Mailing Address:
Signal-0-re- Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building > , "f�000 (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) w 4COO Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2010-0023
APPLICANT/CONTACT PERSON EDWIN OLANDER
ADDRESS/PHONE 97 CHESTNUT ST FLORENCE (413)695-5580 Q
PROPERTY LOCATION 106 CHESTNUT ST
MAP 17C PARCEL 088 001 ZONE URB(l00)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction:_REPAIR FRONT PORCH
New Construction
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included:
Owner/Statement or License 049348
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION 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
Pemiit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolitio Delay
Z
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.
,.� ST BP-2010-0023
GIs#: COMMONWEALTH OF MASSACHUSETTS
B ock:17C-088 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-2010-0023
Project# JS-2010-000032
Est. Cost: $4000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group EDWIN OLANDER 049348
Lot Size(sq.ft.): 10759.32 Owner: MCINERNEY TAKLA A&MAUREEN CONROY
Zoning URB(100)/ Applicant: EDWIN OLANDER
AT. 106 CHESTNUT ST
Applicant Address: Phone: Insurance:
97 CHESTNUT ST (413) 695-5580 0
FLORENCEMA01062 ISSUED ON.71812009 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR FRONT PORCH
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 7/8/2009 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo