17A-275 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
insp--ect wor various stages wii-ciciude foundationlfootings ( efre i3ackf3ll)•
sonotube holes (before hour) 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:tl work—can-be fin
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 fo schedule all required buJilding inspections necessary for the building permit
issued to me.
Date
Address of work
location
The Commonwealth of Massachusetts
Department of Industrial Accidents
01" J, Office bflnvestiaations
° 600 Washinb on Street
Boston, MA 02111
www.mass.gov1 dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers
Applicant Information 13 4- S',of V C_� Please Print Leeibly
Narne (Business/Organization/Individual): _
Address:
City/State/Zip: /A rr A Tak) 14' Phone#: "6.Are u an employer?Check the ppropriate boa: of project(required):
am a employer with / 4. ❑ I am a general contractor and I New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner-
These on the attached sheet. 7. ❑ Remodeling
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.:
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
officers have exercised their 1 I�Plumbing repairs or additions
�.❑ I am a homeowner-doing-all werk -- -_ _._____
myself. No workers' comp. right , 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#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 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 thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#:0r��—31S `.3c Z��J a 19 Expiration Date:0�� �����
1a
Job Site Address: I O V x/74 t, City/State/Zip:r /0
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
tine up to-$`1,500:00-and/oro-ne=yearimprisonment aas 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 ains andpenalties of perjury that the information provided abuve is li`ue and correct.
S1Enature: � ^ 'Jl ex Date: '
Phone#: 1�� ��
Official use only. Do not write in this area,to be completed by city or town official
Citv,or Town: !Permit/License#
Issuing Authority(circle one):
-1. ar-d- ea"—2 Rn#ldUgr-Depa-rtnwnt 3. City/Tuwu Cleik_4..Eltetrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: , >.1 L /
License Number
Addres Expiration Date
Atil
Signature Telephone
.� s Ae -Vii` 7
9,Rediste ed:Hnn eh uioveme ti0ont#actor . . :; s ., '. Not Applicable ❑
73,4 vA1 S d
Company Name / If Registration Number
Addr ss Expiration Date
J�' "'A� � N M,4-
' Telephone � � -11G�/ GL/,
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MG.L.c.152,§25G(6))
Workers Compensation Insurance affidav' must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildi permit.
Signed Affidavit Attached Yes....... No...... ❑
}
N Cnx Ezeti> 4
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-o€the-work-for-which-this-pet s-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
u Y
s
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Wi doves Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [p Siding[V Other[❑]
Brief Description of PrrDX5ed
Work: uL JU tN i'N U N l
Alteration of existing bedroom Ye No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa �f:New..�iotrse nc c�>"addi#o •to.;"Istfili'd hour nA,cotri let Me allo rct
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 74-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRA'CTORAPPLIES.FOR BUILDING.PERMIT
as Owner of the subject
property
_._Hereby authorize
to act on my be s rela' work authorized by this buildinq permit application.
Signature 6-w h&' Date J
f4 g,/O!X as Carr/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 Na
- - .1_ 6
Signature of'Owmw/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
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: i
(volume&Location) '
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0._. YES 0 ..w._. _.__.....
IF YES: enter Book = Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 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 0 , 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 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 0 NO
IF YFS,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton Status tf�ntt r` �
�'p�g
Building Department Curb ut"' V V_
212 Main Street Se+ ef{SeplSCAy��btirty
Room 100 a# rluvell Ava+l ,l,t
Northampton, MA 01060 Tcrsets of Strctirral Flans
phone 413-587-1240 Fax 413-587-1272 Plcit5►t>*Plans :x
{1tf1e'r'Speafy
t
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ,
SECTION 1 -SITE INFORMATION- -
1.1 Property Address:
This sections to be completed by office
Map _Lot Unit
Overlay District
.Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT!
2.1 Owner of Record:
Name(Print) Current Mailing Address:
JTelephone
Signature J
2.2 Authorized Agent: del
Name nt) Curr nt Mailing Address:
,7/ A� - rG 0) 6166 6
Signature Telephone
SECTION.1-ESTIMATED CONSTRUCTION COSTS
Item Estimated-Cost{Dolla.rs)-to-be Official Use Only
completed by ermit applicant
1. Building 0 0()6 (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=(1 +2+3+4+5) Q irJ Check Number
...-Tfiis Section For Offncial Llse' ni
`
Date
.Building Permit Number:
..Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2010-0027
GIs#: COMMONWEALTH OF MASSACHUSETTS
M £ : CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2010-0027
Project# JS-2010-000038
Est.Cost: $20000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R SIDING 100465
Lot Size(sq. ft.): 10715.76 Owner: ELLS PETER J
Zoning.URB(l 00) Applicant: B & R SIDING
AT. 154 OAK ST
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:71812009 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS/SIDING
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 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo