32C-287 •
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 roil h 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 el Investigations
` 600 Washington Street
;." Boston, MA 02111
=u'
www.mass ov/dia
• Workers' Compensation Insurance Affidavit: Builders/ Contractors /EIectricians/Plumbers
Applicant Information Please Print Legibly •
Name (Business /Organization/Individual): _ 1/4;■
Address: J
Cit /State /Zip: V2 IIvtC p l6 6 Phone #: (-(( 3 - �{
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction
�I�am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling
snip and have no employees These sub - contractors have 8. ❑ 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 10.0 Electrical repairs or additions
i
h
d i
h
ffi
ocers have exercised their 11.
3. ❑ I am a homeowner doing all work ❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 ,.00f repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
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 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 certify under the pains and penalties of perjury that the information provided above is true and correct
Signatur Date:
Phone #: 3 - q 4 1 ' 3c-13
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 : 1v'�1 3 ;'7.0 .1' 7 2. 1 1
l License Number
Address Expiration Date
Sig re Telephone
9. Registered Home Improvement Contractor `' Not Applicable ❑
14. JCA.1 mac( t411gri5 j to/3 qC2
Company Naene Registration Number
S OI." • LA: — t _ -O ( 3
Ad Tess C Expiration Date
Telephone U (t3 ( I L ( f l -3`i4
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. -'Home Owner 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 1083.5.1.
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
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) n Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [Oj Decks [D Siding [o] Other [Q]
Brief Descripti of Pr[oposed c�^^
Work: '�'�`cc`s2 i Y
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes v,... No
Plans Attached Roll - Sheet
6a. If New house and or additi to_ exi housing, complete the folt
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
vl ' G. c,v\ ---- Slq Ale—i v , as Owner of the subject
proporty
hereby authorize 4Att'r-t ,_\ ?c':\
to ct on my behalfi n all afters iielative to work authorized by this buildin perm't application.
(
1 2.1 1 (2
Signatu — Owner — — — — -- — -- — ate
I \\ ' ' E Zc: - , as Owner /Authorized
Agent hereby d are 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.
r
Print Name
A ignof Owner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required b y Zoning ,..,,
This column to b `filled in by '` it
Building Department ,'
•
Lot Size .___.____.____._.__ _ __ .. _ _ . -„ _.. _._ F t
Frontage :- r
Setbacks Front
Side L: -- R: _. _._ L: _._._1 R ___. .,..____J
----
Rear _.._ L_______:
Building Height
Bldg_ Square Footage ___ % r ____., ,_.,_,.__ 1 ,.___ ,
L ___ ,..__._.._..,
Open Space Footage _ % - -- - -,
(Lot area minus bldg & paved _._�. u _ 1 ---- .1
parking)
# of Parking Spaces -
Fill: {
(volume & Location) - -- _. _.-._
m --- .-------- --- . _....______. _ _
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW ti)%...... YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW . YES 0
IF YES: enter Book ; Page; and /or Document # i
B. Does the site contain a brook, body of water or wetlands? NO rj DONT KNOW 0 YES i'
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 I NO t 4
M
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 ''1
IF YES, describe size, type and location: i
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 YES, then a Northampton Storm Water Management Permit from the DPW is required.
V I
u onfy
■ 4 of Northampton Sta , f tz r ¢
�� 1, 0 B Ming Department Curb "' s enay Perm � r p
` 2 Main Street Sewer/Septi � ,
e �� c yA Room 100 WaterlWeIl A airabi a 11 '
Northampton, MA 01060 T wo Sets r tP ''..
• one 413 -587 -1240 Fax 413- 587 -1272 PIotISrte'P amens = A ' " ;
Other Specify ` :
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
1 0 — \al i Map Lot Unit
k.4).., '.C:.MMS $r - Zone Overlay District
( C I M ? , Y1 EIm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: ( I `
_ � . �, +_ \ 7 _ -PA, 1.ck IA I -! L I a k -. I( C A0.1 2 K4/l MCt.
a e (Print) k 1 Current Mailing Address:
j r____v___,_. eto- jai - 3
k- w 4
Signature
2.2 Authorized Ape ( - �/
' .r1r Ll 37C ( - rJ. ' 4 ..IA - • `t" vf aCtj lkh .
Name (Print) Current Mailing Address:
1 4 l3 - 5 . 4 - 343 i
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit 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
b 6. Total =(1 +2 +3 +4 +5) Check Number / /1f if') b s
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissionerlinspector of Buildings Date
120 WILLIAMS ST BP- 2012 -0737
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 287 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2012 -0737
Project # JS- 2012- 001291
Est. Cost: $15000.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HENRY J SOUZA 087984
Lot Size(sq. ft.): 10497.96 Owner: JENKINS BENJAMIN J & KATHERINE
Zoning: URC(100)/ Applicant: HENRY J SOUZA
AT: 120 WILLIAMS ST
Applicant Address: Phone: Insurance:
62 SOUTH MAIN ST (413) 949 -3431
FLORENCEMA01062 ISSUED ON:2/22/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE 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 Signature:
FeeType: Date Paid: Amount:
Building 2/22/2012 0:00:00 $90.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner