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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
jermits 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
1 , 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
,
1 ,
The Commonwealth of Massachusetts
Department of Indus Accidents .
I
Office of Investigations
,.. =41111E-7 600 Washington Street
vt =VW 4
Boston, MA 02111
-%;-......-..- • , www.mass.gov/dia .
' . , ...
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organt.z ation/IndivicinaD: ( fr- a_ f
• 66 A
Address: .- - - - 4 - -- c -- 1 .--- r --- )4,--„,, p Q,-(--- z.)---- „ . •
iv, _ op-70
City/State/Zip: pia k - y •-vc_ Phone#: 4 1/ 3 ,c3 7v)0
Are you an employer? Check the appropriate box: Type of project (required): //'
1. at am a employer with • 0 I am a general contractor and I
6. 0 New construction
have hired the sub-contractors
employees (full and/or part-time).*
listed on the attached sheet: 7. 0 R
2. 0 I am a sole proprietor or partner-
ship and have no .)loyees These sub-contractors have. 8• 0 Demolition •
envloyees and have workers' .
working for me in any capacity. 9. 0 Building addition
_ comp...insITmn t . ,_,___
[No workers' con:fp. inniance
10.11 Electrical repairs or additions
require] 5. 0 We are a corporation and its
3. 0 I am a homeowner doing all work officers have txerciseci their 11.0 Pluming repairs or additions
.,. b •
myself [No workers' comp. right of exemption per MGL
12.0 Roof 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 infonnation.
t Homeowners who submit this affidavit indicating they are doing atl wont and then hire outside tnntractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contract= and state whether or not those entities have
employees. If the sub-contractors have employees, they must provide their workers' comp policy nuimber.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: t.-1 I . • •
,
A n n 1 Policy # or Self-ins. Lic. #: \I DJ C (9 Li ti ,,,L ..) V / , u 1 1 -/ l• Expiration Date: - iivo,1(
Job Site Address: p,..6 '3 Pi--05i7-,-7z 5-1-- /1 city/State/Zip :' 1 A 0/0-70
Attach a copy of the workers' compensation policy declaration page the policy number and expiration date).
Failure to secure coverage as required wider Section 25A 'ofMGL c 152 can lead to the imposition of aiming penalties of a
fine up to 51,500.00 and/or one-year iniprisonmenA as well as civil penalties in the form of a STOP WORK QRDER. and a Erse
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Th.feitikations Of the DIA for insurance coverane verification _ ... . - . „
I da hereby certi tin . the ains penalties ofperjoy that the informationprovidertabove is_true_andconfect.____
61 f...._
Sign / I 0 jk5...
ature: I ' Da: g — 3 0-yo • •
Phone ii: . ,
7c D- 7 /0 - - - . .
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. ElectricalInspector 5. Plumbing Inspector
6. Other , f- . •
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
V
Name of License Holder : Y' (t'X j---
1q� F 3 /� License Number
I -i` ' n 1 i1, , , o I®7! �y VV
Address �� , ���� ddd' ' atijilt----- Expiration Date
7‘7 It - 5=D-iii
Signature Telephone
9. Rettis teed Ho`iiiilmnrovemertt: ontr`actierM , .,. �„ nlie IWO= Not Applicable ❑
l,�g /3
Company Name Registration Number
(2.- 3o-- 'o
Address Expiration Date
Telephone /— 2----061"
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 "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 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 ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ® New Signs [0] Decks [ Siding [0] Other [0]
Brief Description of Proposed I 1 ep &u.,4
Work: 1 Out FIrw - egr� 'BY t) k _bat w P i.vn �,. Feto+P) f' 4 COel'e
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ,>( No
Plans Attached Roll - Sheet
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? kj o 1 S I j- ) l
d. Proposed Square footage of new construction. Dimensions /19, /60 /y ' }"�•X
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 10 CC)C/
1. 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 Ta'- OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, Jia p ^eiJ R it _b ) A , as Owner of the subject
property
hereby authorize 6 /i4'( b 2It
to act on my b -half, in all afters relative to work uthorized by this building permit appli tion.
'ature . Owner ' Date
I, _`ii�',riri� , ,1 . r _ ..� g ar — . . _ _ ay , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true an • accurate, to the best of my knowledge
and belief.
Signed under the pains an p nalties of perjury.
Print Name'
Sign of Owner /Agent Date
r ,
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
1? L. 1 -1
Lot Size :
Frontage '
Setbacks Front I I 1 1 I
Side L: _i R:1 L:! R: I
Rear = 1 I ,
Building Height j , I
Bldg. Square Footage = E % iml i
Open Space Footage
(Lot area minus bldg & paved i I i 1-1
parking)
# of Parking Spaces
Fill: r „ _ _. ,..,...._.v .,._, _. w�.�.. _____, w.__�..�,w,_,......�_�...: _
(volume & Location)
i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:I
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book 1 Page and /or Document # i�
B. Does the site contain a brook, body of water or wetlands? NO Q 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 ,Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: I
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
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 O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
a $ z
City of Northampton ,t �l i ` ,
Building Department a k ii X, g
�� 212 Main Str z :t2K
3 \ Room 100
21 :Northampton, MA 01060 '' - = � r '-
phone�.4�1 -3- 87 -1240 Fax 413- 587 -1272 _ � : r t
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
11 7 — 1 ?`i Pry ec -t :ft Map Lot Unit
No r-ti'
Zone Overlay District
Elm St= District ' ` CB. District
SECTION 2 - PROPERTY OWNERSH1P /AUTHORIZED AGENT
2.1 Owner of Record:
,_� V PC bN■,,. a *1 17 a rciui., 3-i- .>r4 it
Name (Print Current Mailing Address:
/ f —� Telephone 3 / � -7— (:).:::<<%5
Signature
2.2 Authorized Agent: i � Q
( -E'Nzi LQ A e,. L. i.,, if , . 6 3 Prosf ec i JT � Jvti lP� t� A 61°7°
Na e (Print) Current Mailing Address: j2 LLL—
CI 13- `2 — 1/ e
ig ature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 9000 I D� (a) Building Pemtit Fee
2. Electrical 7 (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit G Fee
4. Mechanical (HVAC) J J
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number Z
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature: / mi l /1
Building Commissioner /Inspector of Buildings Date
•
177 PROSPECT ST BP- 2011 -0177
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 059 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- 2011 -0177
Project # JS- 2011- 000295
Est. Cost: $4000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GERALD ARCHAMBAULT 010788
Lot Size(sq. ft.): 5009.40 Owner: ROBINSON STEPHEN C
Zoning: URB(100)/ Applicant: GERALD ARCHAMBAULT
AT: 177 PROSPECT ST
Applicant Address: Phone: Insurance:
171 WEST ST APT K (413) 552 -7410 () Workers
Compensation
WEST HATFIELDMA01088 ISSUED ON:8/30/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REBUILD FRONT PORCH (FOOTPRINT),
REPAIR BACK PORCH
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 8/30/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
•