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DEPARTMENT OF BUILDINIG INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Buildin.,
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 1083.4 to
act as his/her construction sup,::-, sor. 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 any 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
location
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d 600 Washington Street
Boston, MA 02111
s�" W www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone.#:
Are you an employer?Check the appropriate bog: Type of project(required):
1.El I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
2. am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
Iworking for me in any capacity. employees and have workers' 9. ❑Building addition
U-40 workers' comp.insurance co—.' "=�=r-ce t
required.] 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 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 CheCVS box 41 must also till 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.
xContractors 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
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 c iffy under the pains andpenalties of perjury that the information provided above is true and correct
Si ature: Date: ' -
Phone#:
Official 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 Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9.Re isfeied Horrie'_Im to"vement Gontracfor-`. ,' L „` �, .¢M<' _ -b :_ Not Applicable ❑
Company Name Registration Number
lo
Addres r Expiration Date
4-- t 'i f�!�1 � Telephone 1
SECTION 10-WORKERS'COMPENSATION INSURANCE;AFFIDAVIT(M.GL.c.152,§15C(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....... 13" No...... ❑
11. Home Qwnerxxei> l� e
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 buildine 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
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) 0 Roofing
Or Doors D 1 06
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [[] Siding[0] Other[a
Brief Description of Proposed
Work: �f 1 !r^,t• Y� V_
Alteration of existing bedroom Yes No Adding new-bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa If New�'fi use•a`_n ora dif dd,f6,V giin44®using. c mri(et th�xfat�or ri c:
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 o. s cons ruc ion wi 'i -----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-70,BECOMPLETED 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 authoriz-edlay this building permit application.
L
i � � —�ef::�
Signature of Owner Date
as 10Wrisi;Authorized
Agent hereby declare that the sta-Tements 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.
Print N e
r`
Signatufe"of Owner/Agent 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
Lot Size
Frontage
Sctbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
(volume&Location)
A Has for/on site?
..~ ~'t^ ~~.. . ...... 0 .^~ 01 �� �� ���---- �_--
IF YES, date issued:,
IF YES: Was the permit recorded mt the Registry of Deeds?
NO K ) D
��
IF YES: enter Book Page. | and/or Duoumont#� |
----------~ --------' --'---------
B. Does the site contain u brook, body of water orwetlands? NO Q~~' DON7K0OV 0 YES 0
IF YES, has u permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ^-� Qbtmimmd x°� Date
�
�~� �~� '
C. Dua�sig� ��� t� pm��? YES NO
IF YES, describe size, type and |uoodun:
D. Are there any proposed changes toor additions of signs intended for the property? YES K ) NO
IF YES, describe size, type and location: '
E Will the construction activity disturb .grading.excavation,m filling)over 1 acre mis it part ofacommon plan
that will disturb over 1acre? YE8K��l NO ��4-
w�
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton Statustiof Pem�it W u
__
Ilding Department fur Ivu yews
_ �e zttt g
;X12 Main Street �veris p tc��i16b 116 b! " 4
—._ - - Room 100 le tF rraabr� � A
Northampton, MA 01060setsoiStrcua>�Ea � � ,
MAY - k
h413-587-1240 Fax 413-587-1272 Plot/Site'Plans ;
atl►er Speclfjr j s
pPLICATION TO CQ`s$TRUC b ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
"SECTION 1 -SITE INFORMATION
This section to be completed b�rofftce ?
1.1 Property Address:
f i Map Lot Unit
_ Zone Overfly !strict
�ElinSt Dlttrict . CB DGStnct
SECTION 2-PROPERTY`OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: -
Name(Print) CuFrP`ast,Mailing A dress:
_�: - —
Telephone
Signature
2.2 Authorized Agent:
Name tint) v Current Mailing Address:
Signatu - Telephone
SECTION 3 ESTIMATED CONSTRUCTION>COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit 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
6. Total=0 +2+3+4+5) q -f Check Number a This Section For Official'Use Only
Date
Building permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
i
BP-2008-0985
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit# BP-2008-0985
Project# JS-2008-000500
Est. Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CDT CONSTRUCTION
Lot Size(sq. ft.): 11761.20 Owner: DEGRANDPRE PATRICIA
zoning: URB Applicant: CDT CONSTRUCTION
AT. 197 BRIDGE RD
Applicant Address: Phone: Insurance:
158 NORTH MAPLE ST (413) 585-8677
FLORENCEMA01062 ISSUED ON:51712008 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 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 si nature:
FeeType• Date Paid: Amount:
Building 5/7/2008 0:00:00 $25.00524
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo