05-040 (3) 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 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 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. y
Date
Address of work
location
Tile Coantnonweaiih of Massacnusetrs
Deparnme;<t of 1ndzzs-zriat Accidents
600 T ashinaton Street
Boston, 2VA 02111
it w-w.inass.a ol'Idia
yy'orkers Compensation Insurance Aflidati-it: Builders/Contractors/Electricians/Pl=.-,rr_bers
ADDlicant information // Please Print Legibly
Na.1e (Bu sin ess!Organizaron'Tndividual):
AjC'zSS: �Q ji.`L'S� G irI9JA1 fNy'%L�JV Jn1 d
City,/State,/Zip: iZ4nM Phone#: 63 y
Are you an employer?Check the appropriate box: Type of project(required): I
I.❑ I am a employer with 4. ❑ I am a general contractor and I
employer 6. F7 New consuuction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑Rem_odelirg
2.[V1 I am a sole proprietor or partner-
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.:
re t irtd d. ❑ We are a corporation and its 10.0 Electrical repairs or additions
q - ]
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 1� �Roof repairs
insurance required.]' c. I-_ §1(4), and we have no
employees. [ o workers' 13.® Other 5;��y� p4t�s
N
comp. insurance required.]
*Any applicant that checks box#1 must also 511 out the section below showing their worker'compensation policy inforration.
7 Homeowners who submit this affidavit indicating they are doing ail work and then hire outside contractor must submit a new affidavit indicating such.
,'contractor that check this box must attached an additional sheet showing the name of the sub-connector and state whether or not those entities have
emplovees. If the sub-contractors have ernployees,they must provide their worker'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Tnsurance Company Name:
Policy 1 or Seif-ins.Lic. F": 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 viGL 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
of up rc S_50.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLk for insurance coverage verification.
I do hereby cerrifv under thepains andpenalties ofperjury that the information provided above is true and correct.
Sicaature, / �� � I_e Date: 1� 4 °0
Phone= (� 3�,_ a 2,3 y
Ojjzcial use onli,,. Do not write in this area,to be completed by city or town ojiciaL
City or Town: Permit,,Ucense f
Issuing Authority(circle one):
I
1.Beard of Health 2.Building Department 3. City/Tow-n Clerk 4.Electrical Inspector S. Plumbing Lisaector
6. Other
1 Conr2c?Person.: Phone
SECTION 3-CONSTRUCTION SERVICES '
11 ^sed Construction Suoerrfsor: Not Appiicable ❑
Name of License Holder: / 12 1
License Number
;ddress Expirat- Date
Signature Telephone
1.Redistered Home Improvement Contractor r, ._._. _._. _.._. ..__ .... Not Applicable ❑
J0
:omoanv Name Registration Number
7-e- _ 7-1 -of
.ddress Expiration Date
tie9 l4? CaAwl y l?&C Rol C,� ,�ko Telephone (03 -.24.7y
ECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G.L.c.IZ2,§25C(6)
�crkers 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.
aned Affidavit Attached Yes....... [J No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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-vear period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Offi cial,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 for you under this permit.
The undersi-ned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Nor-
thampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION ^-DESCRIPTION OF PROPOSED WORK(check all aDoiicabie)
New House Addition Replacement windows Alteration(s) � Roofing � I
Or Doors CI L
Accessory Bldg. ❑ Demolition ❑ New Signs [I]] Decks [C] Siding Other[Ql I
Brief Description of Proposed
Work: Rood X 5:19Aic,
Alteration of existing bedroom Yes _No Adding new bedroom Yes No
Attached Narrative Renovatina unnnished basement Yes No
Plans Attached Roil -Sheet.
ba If New house irf ar addriion:fa ezis.inq flaustnc7:comatete the faI[oin in4
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. flocdpiain 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 Tt?`BE.COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES: =OR BUILDINGPErRMj.T
as Owner of the subject
propel
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Author,--ed
"-.gent hereby deciare that the statements and infom aticn on the foregoing application are true and accurate, to.he best cf my knowledge
,
Iand belief.
Signed under the pains and penalties of pedury.
c:nnt dame
S;gnaiure;f caner,.,aera �'atc
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
s 740L--
Frontage
Setbacks Front
Side L. R. .� / L 39—- R:.9
Rear
Building Height
Bldg. Square Footage
Open Space Footage ��rr
(Lot area minus bldg&paved
oarldnO
of Parkine Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES Q
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES µ
IF YES: enter Book Page and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO t& DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:_ ^M
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 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 or a common plan
that will disturb over 1 acre? YES 0 NO IQ
IF YES,then a Northampton Storm Water anM gemenfPermitfrom the DPW is required.
.I Department use only.
City of Northampton Status of Perrkit:
Bt;Ililding Depariment Curb CutlDmrewayPerrnit
212 Main Street Sewer/Septic:Availability
Room 100 Watei{Wel!-Availability.
JOS Northampton, M' 01060 Two Sets of Structural Plans
phone 413-,587-1240 Fax 413-587-1272 P16t/ ite Plans
S 1 Other Specify
APPI4ICA T ION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELL NG
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Z s 4 V 130N Map Lot Unit
Zone Overlay District
Elift St District CS District
SECTION 2-PROPERTY OWNERS HIPIAUTHORIZED AGENT
2.1 Owner of Record:
/,,1V/d�uLSr d- gOc,�_gg_ SAP 26.5" �<.J✓ /Qa¢ , �r,�s ia,/� O/�S3
Name(Print) CurrentMalin Address:
(Jd Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building g O (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
2+3+4+5) d O d Check Number
This Section For Official Use Only
- Date
Building Permit Number Issued:
Signature:
Building Commissionellnspectoro w omgs Gaie
BP-2008-1113
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: BUILDING PERMIT
Permit# BP-2008-1113
Project# JS-2008-001638
Est. Cost: $8000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin TETON BUILDERS 105301
Lot Size(sq. ft.): 42383.88 Owner: JOHNSON ROGER L&NANCY F
Zoning: RR Applicant: TETON BUILDERS
AT. 265 AUDUBON RD
Applicant Address: Phone: Insurance:
489 W. CUMMINGTON RD (413) 634-2234
CUMMINGTONMA01026 ISSUED ON.611212008 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAI R S I D I N
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 6/12/2008 0:00:00 $25.00515
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo