38B-203 (2) •
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, 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
Date
Address of work
location
- ,
.., .
The Commonwealth of Massachusetts
Department of Industrial Accidents
.-- - Office of Investigations .
600 Washington Street
al ■Imne w ■■•■■■ .,
11 . 1 ; ■ . = * Boston, MA 02111 .
wzr...
' www.mass.gov/dia
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name Musiness/Organiza non/Indivienni):________‘
• Address: 3 i 1 • -
City/State/Zip: f tcite Li r t_ IVO( Phone.#: ( .) )(..)
. ,
Are you an employer? Check the appropriate box: Type of project (required): I
1. 0 I am a employer with 4. 0 I am a general contractor and I
6. El New construction.
I am a sole proprietor or partner-
employees (fall and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. 0 Remodeling
ship and have na These sub-contractors have
)loyees 8. 0 Demolition
working for me in any capacity. employees and have workers'
9. 0 Building - a.ditiOn
_ comp.insuranceJ :
[o wor.kers' comp-. insurance
10.0 Electrical repairs' or additions
5. D We are a corporation and its
3. 0 I am a homeowner doing all work officers have 4xercised their 11.0 Plmnbiag repairs or additions
rieit a exemition per MGL
myself [No workers' comp. 12.0 Roof repahs . -
insurance required] t c. 152, § 1(4), and we have no •
employees. [No workers' 13.0 Other
comp- insurance rerloired4 '
*Any applicant -that checks box #1 must also fill out the section ban showing their workers' compensation policy information.
t HOMCOVILICIS who subrnit this affidavit indicating they are doing all wont 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 enti ties have
employees. If the sub-contractors have employees, they must provide their workers comp. policy number.
lam an employer that & providing workers' compensation insurance for my employees. Below is the policy and job site
irzformatin.
Insurance Company Nanae: •
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 nuinber and expiration date).
Failure to secure coverage . as required inictek Sectibir 25A ofMGL c. 152 can lead to the in:position of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK alma. and a fne
of up to 5250.00 a day against the violator. Be advised 'that a copy of thi.5 statement may he forwarded to the Office of
Itrieitiiitisnis �f the DIA for ins' . :, e Covei:i2ie ieiiliCalicin. --- ----- 77 ----- :,7 -- --- - -
I hereh; s j - ce riz), -- - ,_ 5 pains , " o(p erj ury that the information pioviderliden4 — irlidCitri
/
4 : .
Signature: 1?// f''..--..,./(:_e 4..c Date: / 0
Phone 4: -.-/ 6. • - -
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 , f- •
Contact Person: Phone #:
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ' I Not Applicable ❑
v
Name of License Holder : 114 t° c \ C <, 2 Z (/6,
License Number
31 1 u��� ►z1l
Address Expirdfion Date
t r et-t.62_ Wct
Signature Telephone
3 z -1
9 ::R alstered.Hotiiiewimb ietr►diittoinfmcta ;' . ., > . > � � ,, N A ❑
I� w, r.e3 - � �& I y y'7 z Z
Company Name Registratio N ber
3 I 1 1- k3C -U-3 - S t 1 zo 0
Address Expirati Da e
f I 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 the building permit.
Signed Affidavit Attached Yes No ❑
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 of
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 D ReplacemRX Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [iJ Siding [0] Other [0]
•
Brief Desc'ption .f Prnrosed 1
Work: /. Il4 1 i 1 1 . \ - , . A 1 ; ■ ,. ' 7 ' k 1 . k
Alteration of existing bedroom Yes No Adding new bedroom _ Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
0 1444r re st iiiiiir3 ddi ii 'fa 'e t iiid i iii co de c iti vt ii :
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. Masschedc 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
Z
T �4J C ) S S rCq /l Cr OS $ , as Owner of the subject
property
t
hereby a orize `j) IAA e S
to act on m y behalf in all m s rel i to work authorize by this building permit application.
- / ' j,- t L---- 6' — / - //0
Signa IrliEr - r Date
t
I, ) IAA Ke_s LA G , 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 un er the pains and penalties of perjury.
� 1 C.' , 0.
Print Name ti
..�— / 7,A , ,,d' // / 0
Signatur= .f 1 ner/Ag-nt 1• te
f
• '
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 _ . ,._ _d _ . Y .�.._
Frontage.
I 1 r 1 L
Setbacks Front I i � 1 I
Side L:1 R:1 1 L:1 i R: .J ' 1
Rear = '
Building Height � = i
Bldg. Square Footage 1 1 1 l% 1 1 I J
Open Space Footage , % l
(Lot area minus bldg & paved 1_ j L____ i L,,,_,_.,,,_,a
parking)
# of Parking Spaces 1 #
Fill: .___,,.y..,,..u— w .. — �, .. „___ ., _______
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO -.- 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 0
IF YES: enter Book Page 1 and /or Document # rvN
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 ,Date Issued:
C. Do any signs exist on the property? YES Q NO `'0
IF YES, describe size, type and location: 1 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location: 1
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.
s
• r
City of Northampton ® t� t4: `i � � °
i 1 r - , Building Department �'
_,-, --- "- -- --' 212 Main Street
Room 100P - ®,•
2010 Northampton, MA 01060 4 x• ¢ .
phone 41587 -9 240 Fax 413- 587 -1272 ��;
' t APPLICATIQ}LTO - GINS - UCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
r k Ma Lot Unit
10 ) -17Ak t zone Overlay District
Elm St District CBDlstrlct
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
mss ?�' til
Name (P ) II. Current Mailing Address:
d - (4-7 Telephone
Sigje
2 L_ uthorized A. ent:
, 1 S.,4
,s-4--- '
Name (Print) ry
acao 1 .-----' (
Current Mailing Address:
/ /i✓i
Signature Telephone
SECT ON 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
onstruction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 0i e 0 4.' Check Number06 r
This Section For Official Use
Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /inspector of Buildings Date
X 37 MANHAN ST I BP- 2010 -1152
GIS #: COMMONWEALTH OF MASSACHUSETTS
Iay:Block: 38B - 203 CITY OF NORTHAMPTON
Lot: -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 -1152
Project # JS- 2010 - 001688
Est. Cost: $10000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: '
Const. Class: Contractor: License:
Use Group: KIM RESCIA 022464
Lot Size(sq. ft.): 5009.40 Owner: CROSS JOSEPH G & CATHY G
Zonixig: URB(100).! Applicant: KIM RESCIA
AT: 37 MANHAN ST
Applicant Address: Phone: Insurance:
311 Locust St (413) 320 -1831 ()
FLORENCEMA01062 ISSUED ON:6/17/2010 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: Ok g_ a
CNM-
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND ' . - .I re /� � Ado (?.10401/
/ . /0444
Certificate of Occupa Si gna t ure:
FeeType: D e aid: Amount:
Building 6/17/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo