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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
iermits 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, 4 _____ .
Ali understand the above.
: ome owner /resident s si_ tR ture requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date (' /! 0
Address of work l
location 41 inatix- R-01-
7
.
' . , :•
The Commonwealth of Massachusetts
Department of IndustrialAccidents
75=-5ii= r Office of Investigations •
600 Washington Street
Boston, MA 02111
1...‘,..............7, . , www.mass.gov/dia .
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): A v\,-1 reke P 041 -1.......e--, .
Address: (-( 1-0 6 e-. 1 - 60 t4A4.' _.-/-1, . .
City/State/Zip: finreA.t.tz 04 i4 Phone.#: ( (3) Ciq c gsz 2.._
Are you an employer? Check the appropriate box: Type of project (required): 11
1.0 I am a employer with 4. 0 I am a general contractor and I
6. 0 New construction
hired the sub-contractors
employees (full and/or part-time).*
listed on the attached sheet 7• 0 Remodeling
2.0 I am a sole proprietor or partner-
These sub-contractors have
ship and have no employees 8. 0 Demolition
employees and have workers'
working for me in any capacity. 9 0 Building addition
iinceA _
[No vvorkers' comp. insurance _ coup. nsun
__ _ _ _
0 required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. I am a homeowner doing all work officers have 4xercised their 11.0 Plumbing repairs or additions
;
myself [No workers' comp. right of exemption per MGL r•-, — -
12.Li /coot repairs
insurance required.] t c. 152, §1(4), and we have no
13.C1 Other
employees. (No workers'
eur insurance surance requiredd •
*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 sty+
:Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees lithe sub-contractors have employees, they must provide their workers' comp policy number.
Jam 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-Ms. 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 OfNIGL c. 152T can lead to the iiiipositiOii of cr1min41 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
Eikations Of the DIA for insurance coveraie verifiCiiiiin. _ _ .. _
Ida hereby_c :67 under th and ' s ofperjtay that the information provided_above_ainie_Undiorreer
Silinattu-e: ' e_i_)- ---41 " ----- Date: t't (2,-1 / (
Phone /k ,
,
,
i : -
I. Official use only Do not write in this area, to be completed by city or town'officiaL
City or Town:
Issuing Authority (circle one): .- Permit/License #
----.........
. 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
LAR‘ciitttlidlibinelnitiiihiniiiiittail.:42 Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. 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 ❑ No ❑
11. 41Hnme :Ovine Exemption;
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, Sta e and Local Zoning La nd State of Massachusetts General Laws Annotated.
Homeowner Signature
CtAr(
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Wr Roofing ❑
Or Doors D _
Accessory Bldg. Demolition ❑ New Signs [O] Decks [I] Siding [0] Other [D]
Brief Description of Proposed
-.- /
Work: . .. .t • A ■• k / - - / . A i - d �
Alteration of existing bedroom Yes No Adding new bedroom if Yes No /
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
.a.: If .. bi s a d rir i . Itto t # lkiiiil it hfous nii; 6currii i i+ 1 oitowinq:
a. Use of building : One Family Two Family Other V
b. Number of rooms in each family unit: '7i Number of Bathrooms 1
c. Is there a garage attached? WO
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? pp ,/ t
f. Method of heating? 2 ,e ( /l f ilr� V 1 Fireplaces or Woodstoves Number of each
g. Energy Conservation Cpliance. 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 V Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , 1 1 . vv,W4A.,) e_,-/P �
as l / , as Owner of the subject
property J
hereby authorize y
y q..r.) (' Gc uildi �
to act • n my behalf, i i - II matters to work authorized by th uilding perm appl
4V / tt Zfio
Signature of Owner Date ( 4
I, , as Owner /Authorized
Agent ereby declare that the tate nts and info ation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed un er the pain V and penalties of perjury
r ... 1 A V -e,G3 e. - a 52---
Print Na e
n.& L4 > r . Ai •. .
Signature of Owner /Agent
0 Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
t
;, A C This column to be filled in by
Y w / `y � �� � p P � Building Department
� .. .,.....s._ , .,..,, .
Lot Size I t 7 3 )( 4'(� d z ,
Frontage C 73 i
Setbacks Front a;
Side L:i "` ' R:L6. L:L, i R: ...„_' ,
Rear FW I 1
Building Height ,r L____! 1
Bldg. Square Footage F % 77 j 1
Open Space Footage % r _._._,
(Lot area minus bldg & paved 8246i _ i
parking)
# of Parking Spaces ---
Fill:
I I'
(volume & Location) i,, - -
A. Has a Special Permit /Variance /Finding er been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book 1 P agel I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 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 , Date Issued
C. Do any signs exist on the property? YES Q 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 (J
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, exc tion, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton fal��
Building Department -
9 p � s �
212 Main Street - r"
Room 100
NN orthampton, MA 01060
,y 2 j phone 413 -587 -1240 Fax 413- 587 -1272
mod,...
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
L t - 'J gy p Map Lot Unit
Zone Overlay District
Oto Ci L. Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) J Current Mailing dd ess:
p Lei 3 1 qc
A ,.t 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 c • (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
(j0 Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection ! G/ 0
6. Total = (1 + 2 + 3 + 4 + 5) r c) Check Numbe '
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
•
File # BP- 2011 -0497 '
APPLICANT /CONTACT PERSON PAYNE ANDREW C & LORETTA M KANE
ADDRESS /PHONE 470 BRIDGE RD FLORENCE (413) 695 -8562 0
PROPERTY LOCATION 470 BRIDGE RD
MAP 17B PARCEL 006 001 ZONE RR(100) //RI
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out �c
Fee Paid � yv�5 _
Typeof Construction: CONVERT ART STUDIO INTO DET ACCESSORY APARTMENT _
New Construction S tA.oI: E atop C8 n i tC o tt5 P(-(L C-w124'Z15N \ CO A C
Non Structural interior renovations I N S Pecric p 11.4tiak 0 to yz.4,6 et. - o
Addition to Existin • , • .� 2
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Building fficial Date 2/ 2/10
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.
__ v
•
C . ' _• BP- 2011 -0497
GIS #: COMMONWEALTH OF MASSACHUSETTS
:m „ " CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ACCESSORY APARTMENT BUILDING PERMIT
Permit # BP- 2011 -0497
Project # JS- 2011- 000259
Est. Cost: $5200.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 74052.00 Owner: PAYNE ANDREW C & LORETTA M KANE
Zoning: RR(100) / /RI Applicant: PAYNE ANDREW C & LORETTA M KANE
AT: 470 BRIDGE RD
Applicant Address: Phone: Insurance:
470 BRIDGE RD (413) 695 -8562 ()
FLORENCEMA01062 ISSUED ON:12/6/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: CONVERT ART STUDIO INTO DET
ACCESSORY APARTMENT - SMOKE & CO DET PER CURRENT CODE, INSPECTION
REQUIRED PRIOR TO WORK STARTING
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 12/6/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner