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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 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
^V —^
Office o(fhzvestiaations
3 )�� f✓ ✓b
600 Washington Street
Boston, 31A 02111
www.rnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers
Applicant Information Please Print Legible
Name (Business/Organization/Individual)'�
Address:
City/State/Zip: ff( 0 i3 Phone #: �l/3 '�� ` � 7
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a with employer 4. E] I am a general contractor and I
Y � 6. New construction
employees (full and/or part-time).* have hired the sub-contractors
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. E] Demolition
working for me in any capacity. employees and have workers' 9 0 Building addition
[No workers' comp. insurance comp. insurance.t
required.]
5. F_� We are a corporation and its 10.7 Electrical repairs or additions
3.❑ 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 —
�L
1 3. ' Other /h+A/� e �`L//
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 indicadne 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. �nn �/ _
Insurance Company Name: X. M, /9 /axll L 6ef 4 NGe- w i 1 W- 1 R,
Policy#or Self-ins.Lic.#: I/W e (P '" 4001 ? o!— Expiration Date: Z—L4 O
Job Site Address: ql) a,(1 kip'. City/State/Zip: L_e,6Si MA,
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 er he pai an nalties of perjury that the information provided above is true and correct.
Siena-re: 4/— Date: — ZZ--
Phone#: 3
Of use only. Do not write in this area,to be completed by city or town offcciaL
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#:
I
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: �; (fin—. �� e--
License Number
611 e4eea:,�- C,4A t A ov
Address Expiration ate 000F S
Sig ure y Telephone
C9. Registered Home lmprovemenf Contractor: Not Applicable ❑
� -
ompany Name Region Number
Address =/ T r 3 Expiration Date
z Telephone )
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MG.L.c.162,§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 pe,unit.
Signed Affidavit Attached Yes....... No...... ❑
11. Home Owner EXemptio3n.
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 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
c�>
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors E-1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[O] Other[
Brief Descr do of Propose J t
Work: � 1 iq f:L C'4 ' — C t4 e.'—'
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing 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 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
as Owner of the subject
property
hereby authorize
to act on my ehalf, in all matters relative to work authorized by this building permit application.
Si ur ner Date
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.
Print Name
Signature of Owner/Agent Date
��J
Section 4. ZONING Alt 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: ._ ....w 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 0 YES 0
IF YES, date issued:`
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q 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 0 NO 0
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 Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department.use.only,
City of Northampton Status of Permit
Building Department Curb Cut/D iveway
212 Main Street Se,jrer/Septic'Availability
Room 100 Water/WeltAvailabifity
�j1'= Northampton, MA 01060 Two SetsoffStructural Plans.
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other'Specfy
APPLICATION 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
Map Lot Unit
Ut Du��
p /�] Zone Overlay District
�-x!'�-�•.5 I I , I�����J/'� Elm St District GB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
LY IV OL[_ 4AjC14 go d �/��hc�' /So 30 c�
Name(Pn Current Mailing ddre s:
ZF&A Try, -
-
Telephone
ignature a -- fo"0 7a G
2.2 Authorized Agent:
C- 67F G imve S TFrh.I , Jot-� f'� h i e o,l✓e
Name(Print) Current Mailing Address: j V-T 0/v t 3
3--5f!K_
Signatur Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building Q (a)Building Permit Fee
2. Electrical Q (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building'PermitFee
4. Mechanical(HVAC) e;k" 114ei
!//ll
5. Fire Protection 0 V "�
6. Total=(1 +2+3+4+5) / Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
C/
407 AUDUBON RD BP-2009-0547
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 05 -060 CITY OF NORTHAMPTON
Lot: -001, PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate or : BUILD►ING PERMIT
� v —
Permit# BP-2009-0547
Project# JS-2009-000768
Est.Cost: $3150.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class__ Contractor: License.:
UseGrouR.— THERMOCRETE '..;H.IMNEY SYSTEMS 161507
Lot Size(sg. ft.): 760993.20 Owner: BRANCH LYNI LL M
Zoning: RR(lool%/V P/WSP Applicant: TF ER�M�RETE CHIMNEY SYSTEMS
Applicant Address: Phone: Insurance:
46 JOY ST (413"i .594-8764 WC.
CHICOPEEMA01013 ISSUED ON.1112012008 0:00:00
TO PERFORM THE FOLLOWING WORK.-RELINE CHIMNEY TO WOODSTOVE, CAST IN
PLACE
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: • 'Ifouse# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney: VK
L0144
Rough: Oi'-: 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 11/20/2008 0:00:00 $25.00290
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Coraraissioner-Ai,','hony Patillo