38B-185 L
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
regui tions Th_ a insne_ctionp ocea &equi. es 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- con}unction_to the building.permit issued,_ 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
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V L-1-7. , --"Ar- - -r-
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,
Office of Investigations
600 Washington Street
Boston, MA 02111
. •
www.mass:govidia .
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeEiblv
Name (Business/Organization/Individual): etc Pej 4 ,, ',
• Address: *51 S 1 1QTRACk. 12 -6 . .
City/State/Zip: 1 - , \ VA-- 0103 \ ---- Phone #: 9( - 6 Fay
r, I
Are you an employer? Check . . ropriate box: Type of project (required): l'
Warn a employer with Z____
• El I am a general contractor and I
6. 11 New constru.ction
have hired die sub-contractors
erriployees (full and/or part-time).*
listed on the attached sheet. 7. lain
2. 9 I am a sole proprietor or partner-
These sub-contractors have
ship and have no enTloyees 8• 0 Demolition
• '
working for me in any capacity. employees and have workers 9. 0 Building addition
' e.I
ins uranc
[No workers' comp. insurance comp .
10.0 Electrical repairs or additions
required.] 5. 0 We are a corporation and its
d their --1 repairs or additions
3. 0 I a
am a-homeowner-doing-all-work _Offic.ems_haci.2%ercise
,
right of exemption per MGL
myself [No workers' comp. 12.9 Roof repairs
insurance required.] t • C. 152, §1(4), and we have no •
• employees. [No workers' 13.0 Other
comp. insurance repired.j
*Any applicant that checks box #1 must also ffil 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
ernployees. If the sub-contractors have employees, they must provide their workers' comp. policy number.
I anz an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
i_xformation. _ 4. _ 1,,t_ . i ( _ ,
Insurance Company Name: e 1\_,Q. ft_ _ A • •
Policy # or Self Lic. #: (9 - 5 - 7 13 9 c) 9,)-- Expiration Date: -
Job Site Address: 3'3 2g..-i Yi / , iuen—ikpk.,_\. 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 S1,500.00 arid/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a e
of up to S250.00 a day against the violator. PI e advised that a copy of this statement may be forwarded to the OffiCe of
Investieations of the DIA for ins • . • e coverane verification.
I do hereby ce 357 nder ' an Ana.lties ofperjury that the information provided ..above_is_true suld_correct._____
Date: _
__I ....
y
si• ..ture: 41104MM A --
i t / 7 07
—
Phone #: 9 — - 6 rai - - •
- Official use only. Do no WTI& In - this to completed by el° or town officiaL
City or Town: Permit/License #
-- - -
Issuing Authority (circle one):
• I: Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbinawector
6. Other ,
•
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su isor: Not Applicable ❑
Name of License Holder : l'(•'0 M,(Jcz. - Y'] / `f . J ...A. •
11' ( r �+ Ci1dG� �Q �1� ' r- 5/S - 9 0/
Address Expiration Date
' 1 4 IAA
Signature Telephone
9:.Reoistered ,Home; lmprovementContractor ,. ..., . „<< } ,.:Y t..,., Not Applicable ❑
S i �4 - ram. tai Q..) S' �J—(�a3- (e Com an Name t/" J Registration Nu ber
_
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 ❑
The_current_exemption for " homeowine-s" 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
ort ampton •riinancos,_ a e a I _ 4' ' • • ` • •• •• + - Y - - 0 ° • .`° - sGeneral- ba -ws- Annotated.
Homeowner Signature
z
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacemen ndows Alteration(s) El Roofing E
Ur Doors
Accessory Bldg. ❑ Demolition El New Signs [O] Decks [[] Siding [0] Other [0]
Brief DescriptionAf Proposed 1
Work: t �;�_Q (4 VI)? LAJwvArtivS 1! lu1vy ( t�( ,ef..R u, ticttc . 30
Alteration of existing bedroom Yes � ✓
PJ6" Adding new bedroom Yes +.No
Attached Narrative Renovating unfinished basement Yes iRl'o
Plans Attached Roll - Sheet
6 , Ne *hou$e= anctor addi ion'ta existi ng houstnq; 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 la - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/,10
I, 4 -...A.... 4/`! %• ►_ 91 -_- !j 4 - 0 , as Owner of the subject
property
hereby authorize » %ti , �, t !1 .. C-c
to act on relative all matte
my behalf, in matters r to wo authorized by this building permit application.
/ / /Y. 494 k l I l"7 101
Signature of Owner Date
I �` T , ; , � �} „ i e , as Owner /Authorized
Agent ereby declare at the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Sign
p
under the pains and pip 'es of perjury.
- — ' ASo - ,��
Print Name \ ' 0 .---
°' ';‘-' I I .., - - , ■ - - — t 1 - - ( I __ 1- _____
Signature o'-= , ner /Agent Date
_ Y
• s
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 % l_
Open Space Footage chi
(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' YES
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 #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW # YES
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 0 NO a
IF YES, describe size, type and location:
—D — Are there any =proposed changes to or a ttions o signs intenZed te property ? YES (3 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 of a common plan
that will disturb over 1 acre? YES 0 NO
J10
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton '5 o erm ` f � 5 � *
Building Department � d V e . -i , f `�
212 Main Street Seuv S = 4D1irIO(tt
Room 100 7 ws
i •' , , ,ra i � s t
phone 413- 587 -1240 Fax 413- 587 -1272 � 3 o j
APPLICATION TO CONSTRUCT, ALTER, REPAIR. _RENOVATEISR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION ��(�`� 1, c'vl
1.1 Property Address: This Gectiop to be completed by office
("e s � ` _ M ' z -- - tot Unit
p Zone Overlay District
"��✓ Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record e,
x:! : = .% � -I-� t6/44,,,A
'3 3. :., .3-1- . / iv -1142 v10
Name (Print) Current Mailing Address:
fri //-6 i Z - I Telephone 3 Y? - Y 1
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 �l,��lJe rsv (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
/1 6, Total (1 + 2 + 3 + 4 + 5) ' Check Number . •
This Section For Official UseOnlq '
Building Permit Number: Issued:
Signature:
I Buliding Commissioner /Inspector of Buildings Date
iO4 0611.T ST BP- 2010 -0541
GIS #: COMMONWEALTH OF MASSACHUSETTS
tap' :Bt ck; 388 - 185 CITY OF NORTHAMPTON
I.ot; -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0541
Project # JS- 2010 - 000760
Est. Cost: $8000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD PALMISANO 89485
Lot Size(sq. ft.): 9321.84 Owner: POULIOT STEPHANIE & MICHAEL HOLLAND
Zoning: URB(100)/ Applicant: RICHARD PALMISANO
AT: 33 FORT ST
Applicant Address: Phone: Insurance:
87 SHATTUCK RD (413) 549 - 6824 WC
HADLEYMA01035 ISSUED ON:11/17/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 11/17/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo