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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
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 tome.
Date
Address of work
location
The Commonwealth of Massachuse
.w..--;•_-7----- Department of Industrial Accidents
Office of Investigations
• — -1=.--. r.
600 Washington Street
• — .11
Boston, MA 02111
-
N• --;: - - i ,
www.mass 0
, •.• -5 . _,.
•
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organilation/IndivicinAD: ° P ' ad AI
Address:
1CZC ---- :;(A)C- ) S-J-ir\c9vv\r-i-1.-
City/State/Zip: 19 av-t ikcy? MA- 0106e7Phone.#: STRti - 33SZ-
.
Are you an employer? Check the appropriate box: •Type of project (required): 1
1.0 I am a employer with 4. 0 I am a general contractor and I
6. 0 New construction
I am a sole proprietor or
employees (full and/or part-time).* have hired the sub-contractors
2. partner-
6 listed on the attached sheet:
These sub-contractors h 7. 0 Remodeling,
• ship and have no . ave aloyees 8. 0 Demolidon
ps d lia -
working for me in any capacity. emloyee an ve workers' 9. -ET Buildiii addition
[No workers' comp. insurance
requirecL1 • - . 5. 0 We are a corporation and its 100 Electrical repairs or additions
3. 0 I am a homeowner doing all work officers have4xercised their . 11.0 Plumbing repairs or additions
myself. [No workers' conv. right of exemption per MGL
12.0 Roof repairs . •
insurance required) t ' c. 152, § 1(4), and we have no
employees. [No workers' • 13.9kOther l
comp. insurance required.] • -
*Any applicant-that checks box #1 must also fill out the section below showing theirworkers compensation policy information.
t Homeowners who submit thia affidaVit int:Heating 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 ornot those entities have
employees If the sub-contractors have employeea, they must provide their worions' comp. policy ntmther.
lam an employer that is providing workers' compensation insurance for my employees. Below Ls. 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'(sho the policy numb er and expiration date).
Failure to secure coverake . is required mid& Section 25A ofMGL c 152 can lead to the iinpOsitiini of Ciiniinal 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 Offibe of
Efeiiiiitions i:if the for insurance Cove verification
/ do hereby_certzfi un th pains ripen s of 'ray that the informationprovidedabove_ _andeorrprr
Signature: - , " Date; Z ig . .
.
Phone 0: ..
• •
• Official use otzly. Do not write in this cfrea, to be completed by city or town officiaL
•
•
City or Tovvn: .• Permit/License #
Issuing Authority (circle one):
I. Board of HeaIth 2. Building Department 3. City/Town Clerk 4. Electrical,Inspector 5. Plumbing Inspector
6. Other .
Contact Person: Phone #:
• l
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su !.-i, isor. Not Applicable ❑
(�
Name of License Holder : � u t (.. G l .�
II License Number -- it / Address Expiration Date
Signature Telephone
9:sRe . isteia .)to =rove en o ff' 3" . nR< y .. __ Not Applicable ❑
x)� .r,� �. i n Number
2 I
Company Name Registra o
k c P� NSTV, CO, GJf211?_
Address Expiration ate
3 � . 3
Telephone �`�
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GL. 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 y No ❑
i14 ` 11 : Cvnidiraftento
The current exemption for "homeowners" was extended to include Owner - occupied Dwellines 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) 0 Roofing Q
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [kj Siding [D] Other [0]
Brief Description of Proposed� � '� , , }
Work: 1 i -- �> V wi l i � .- c%' GVOLV1
Alteration of existing bedroom Yes K No Adding new bedroom Yes V( No ,P (- 'Q U` I
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll - heet
a. Use of building : One Family Y 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 Ta OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, r -G.. tr)i "1,,,e_,( , as Owner of the subject
property
hereby authorize 0\ A
Accc � �( l — 1 �-���v ""' "v--,
to act on my behalf . II m rs tive to work authorized by this building permit applica on.
Signature of Owne IC) D ate
I .1-- ./ \ a_ J imeA-.... , 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 under the pg � penalties oerjury.
A -°
Print Name C( /(//C) � r vim`
Signature of Owner /Agent Date
9
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 1 / .0 C „d14 _ ,
Frontage GO i 1 i
Setbacks Front
!231 [S
Side L: R: L: R: 1
Rear a
Building Height 77 E 1 1 1
Bldg. Square Footage _ ._ritS W % 14iJc
Open Space Footage
(Lot area minus bldg &paved 2::�_ --; Z.R- -J Z - ._.,.._.,,..
parking)
# of Parking Spaces C
Fill: - - -��
(volume & Location) � 7 .
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0"..* KNOW 0 YES 0
IF YES, date issued:l I
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book g Pa and /or Document #
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 0 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 t
IF YES, describe size, type and location: s
E. WiII the construction activity disturb (clearing, grading ex - vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 41
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
w
g
City of Northampton t
Building Department °
212 Main Street
Room 100
Northampton, MA 01060 �� .,
phone 413 - 587 -1240 Fax 413 - 587 -1272 °
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
Map' Lot Unit
one Overlay District
Efm St District ' CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
4-- M i , (Q, S'' LA ..0 L,° k 4 .
Name (Print) ] Current Mailing Address:
�✓ Telephone
Signat
2.2
t ooi thorized A. ent: VCA
Name (Print Current Mailing Address:
,u - 3 7.
Signat- ' Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
.` pleted by permit applicant
w
1. Building 1 a� (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing _ Building Permit Fee
L ROO
4. Mechanical (HVAC) '..q' '�j v .°
5. Fire Protection
- "'It .-- 6. Total = (1 + 2 + 3 + 4 + 5) � -- Check Number 7 9 6 Sa OD
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Date
Building Commissioner /Inspector of Buildings
File # BP- 2011 -0086
APPLICANT /CONTACT PERSON PAUL MCCUTCHEON
ADDRESS/PHONE 1526 WESTHAMPTON RD FLORENCE (413) 584 -3352 0
PROPERTY LOCATION 38 LINCOLN AVE
MAP 25C PARCEL 090 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
F
Building Permit F' ed out Q
Fee j�, 7 7 6
Typeof Construction: Deck Addition
New Construction
Non Structural interior renovations
Addition to Existing
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
INF9RMATION PRESENTED:
Approved _ 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
F 1(a
Signature of Building Official Date
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.
38 LINCOLN AVE BP- 2011 -0086
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 090 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 -0086
Project # JS -2011- 000158
Est. Cost: $0.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL MCCUTCHEON
Lot Size(sq. ft.): 7187.40 Owner: SQUIRES JOSEPH D & MICHELLE L
Zoning: URB(100)/ Applicant: PAUL MCCUTCHEON
AT-- 3R LINCOLN A' /F
Applicant Address: Phone: Insurance:
1526 WESTHAMPTON RD (413) 584 -3352 ()
FLORENCEMA01062 ISSUED ON:8/9/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: Deck Addition
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter: r./ eee t4 €51€ C rjAA.
Footings:
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: C:)k- IQ 014
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu.anc ''gnature:,,,
FeeType: Date Paid: Amount:
Building 8/9/2010 0:00:00 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner