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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
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 Indust Accidents
4 Office of Investigations •
=.-
600 Washington Street
Boston, MA 02111
www.mass.gov/dia •
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name pusines..i/organiialionaidivich.o:
, -
Address: 3 I \ e- c3 7 1 —
City/State/Zip: + ) L)(-., Phone #: :sec 3 I
Are you an employer? .Check the appropriate box: a general . Ctor and I Type of project (required): /
1. I am a employer with 6. 0 New construction
have hired the sub-contractors
employees (full and/or part-time).*
listed on theattached sheet 7. [;] R.emodeling
2. I ani a sole proprietor or partner-
ship and have no employees These sub-contractors have. .8. 0 Demolition
working for me in any capacity. emiiloyees and have worke rs •
9. 1:1Build iddition
[No workers' comp. insurance
require/I , • 5. 0 We are a corporation and its 100 Electrical repairs or additions
3.0 I am a homeowner dciing ill work officers have4xercised their .
11.0 Plumbing repairs or additions
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' 1 Other 1\121 $1/4.r
comp. insurance reqUired.1
*Any applicant that checks box #1 must also fill out the section below showing their workers' conipensation policy information.
t Horaeownesi who submit this affidavit incficating they are cloing all work and then hire outside c ontractors must submit a new affidavit indicating such.
:Contractors that check this box mast attached an additional sheet showing the name of the subcontractors and stair whether or not those entities have
employees. lithe sub-contractors brie employees, they must provide their workers' comp. policy number.
Jam an employer that is providing workers' compensation insurance for my amployees. Below is the policy and job site
information.
Insurance Company Name: •
Policy # or Self-ins. Lic. #: Expiration Date:
lob 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 reqUitedinider Section 25A 'Of/siIGL c. 152 can lead to the in:3065411' °i penalties of a
fine up to $1,500.00 and/or one imprisonment, as well as civil penalties in the form of a STOP WOW( ORDER and a fine
of up to $250.00 a da against the violator. Be advised That a copy of this statement may be forwarded to the Office of
EfeitlatianS Of the DIA for inanc verane vnflcthion •
Ida hereby cern), un tp penalties of perjury that the information provide
Sirmature: 1 /2//7 7a • _
Phone 32-Y. ...
• - Official use only. Do not write in this drea, to be completed by city or town'officia
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
•
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: 0 Not Applicable ❑
Name of License Holder : 11 l i/lA P SC I C� Z
zq6�/
_ License Number
3 t \ )“-L/H \ s \At0-(. I / / Z. / eC I ?
Address � ! , -� Expiration Date
77 e �(- a .3 ze) / 3
Signetur Telephone
9.Re. Iste prn 1th , ; , .. tC , ri ear• .._ is .mow ;m _ ii ' ,. M F , : Not Applicable ❑
Company Name Registration Number
Address Expirat n ate
Telephone 31 ) —/ C 3 /
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 Nl No ❑
Home wntr xemption
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
r
SECTION 5. DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [] Addition ❑ Replacement Windows Alteration(s;)il Roofing jJ
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [0] Other [0]
Brief Descriptio n of osed
Work: 1,1AS '1 Lk A r , )34 LL1 614 t? .4/ I S Cti 1 r C� rC A
Alteration of existing bedroom Yes No ``, Adding new bedroom Yes No
Attached Narrative Renovating unfinished basemen Yes No
Plans Attached Roll - Sheet
say: t�}l �evir�haus�' �ri�: i�ra�di�to�a���r�stic >�ous°�nq�.�m`p�+��: th�dfrs�towrtp:
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
, ! a ;; (u ( 1 5 ' C, , as Owner of the subject
property
hereby authorize 10t/'\
t'`'+
to act on • • If, in all ma relati rk authorized by this building permit pli tion.
Signature of Owner Date
�
� /j ,�� as Own /Authorized
Agent, reby decl 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 • - alties of perjury.
/l J^'l S (/ Cz�
Print Name
Signature • 0 ner /Agent 'ate
, S P
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 '
Frontage
Setbacks Front 1
Side L:. R: L: L. j R: ? ( .._.__._ J
Rear
E
Building Height i 1 1
Bldg. Square Footage r" a i j % F- l• I I i •
Open Space Footage %
(Lot area minus bldg & paved g , 1 77-1 1
L....
parking)
# of Parking Spaces i -----1
Fill: i
(volume & Location)
I
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO N O 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 I Page 1 and /or Document #'
B. Does the site contain a brook, body of water or wetlands? N0 DONT KNOW 0 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: 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO ID
IF YES, describe size, type and location: it
E. Will the construction activity disturb (clearing, gra 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.
o .
City of Northampton ® = � 5 � ;;ia � ,
Building Department = , . c
212 Main Street m ' _ 'fix 1
Room 100 - . -
Northampton, MA 01060 , - A � ��
phone 413 -587 -1240 Fax 413 - 587 -1272 a
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
7 � � �)�� �a� t Map Lot Unit
)U ar LI i Lti, _ . ) 6'(' Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
r
C > - K ) ' 1,R. ° 0 /._3 -1- e-i,, k (i L, S -I--
Name (Prin a � )
u � ` Current Mailing qd ress: i q
` I �` Telephone , L� Z -L
Signature S 1 - � � '
2.2 Authorized Agent: 1;
Name (Print) '` Cur Mailing Address:
1A I 14-A. l` //r \C )e(fl 3Z e� - /�s_� I
Signatu Telephone
SECTION 3 - 'ESTIMATED CONSTRUCTION COST S
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ' LI ,3 Q \, (a) Building Permit Fee
1 !
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 +4 +5) -- Q'� I v Check Number �` 3
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: c
1 Ci z... -3 8 v
Building Commissioner/inspector of Buildings Date
'')If—IC6
75 WEST ST ' BP- 2010 -0776
GIS #: COMMONWEALTH OF MASSACHUSETTS
malikkk: CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Non structural interior renovations BUILDING PERMIT
Permit # BP- 2010 -0776
Project # JS- 2010 - 001119
Est. Cost: $1400.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KIM RESCIA 022464
Lot Size(sq. ft.): 10759.32 Owner: STANDICK TRUST RICHARD RESCIA & STANLEY ZEWSKI TRUSTEES
Zoning: URC(100) / /EU Applicant: KIM RESCIA
AT: 75 WEST ST
Applicant Address: Phone: Insurance:
311 Locust St (413) 584 -5816
FLORENCEMA01062 ISSUED ON :3/9/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK :INSTALL NEW PORCH FOOTINGS
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 3/9/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo