31C-006 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
regul The inspe ction n ��Eess.�e �uires that the building department be calle 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
— ---------- pemii-ts- in -conj. unction -to- the- building.permitissued, -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.
n�to
Address of work
location
The Commonwealth of Massachusetts
Department of Industrial Accidents -
Office oflnvestigations
t 600 Washington Street
Boston, MA 02111
�„ sv www.mass gov1i a
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
A pIicant Information Please Print Legibly
Name (Business orgmization/individual):
Address -,q �I J
City /State/Zip: /`
o Phone. #: t,
Are you an employer? Check the ap ropriate box: Type of project (required):, /
1. Q I am a employer with 4.. Q I am a general contractor and I 6. Q New construction
employees (full and/or part- time). * have hired the sub - contractors
2- L�hLaai a sole proprietor or partner- listed on the attached sheet. 7- Q Remodeling
T ship nail have no: lo;Tees These sub - contractors have. 8. Q Demolition
working for me in an aci employees and have workers'
Y capacity. 9. Q Budding addition
[No workers' comp. insuran cam. insurance.;
requirecL] 5. Q We are a corporation and its 10.Q Electrical repairs or additions
_ o ce _1�y�x=i� then —1-1 -. m r airs or additions
�. Q I am- a- lismee�vaer -- day$¢- all -work - - - - -- - ���b � g eP
myself [No workers' comp. right of exemption per MGL 12. Q Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required j
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infarmation.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must subsst 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
employees. If the sub-contractors . have employees; they mustprovide their workers' comp..poficy number.
f am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
f
Insurance Company Name:
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/Stafe/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 e. 152 can lead to the imposition of criminal penalties of a
f ne up to $1,500.00 and/or one-year impriso nt as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day a gainst the violator. Tie advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for i-fismar,ce coverage v caton
I do o L n
# here _ I n f er the sins . d ea es , perjury that the information rovided above_Lume-atraeorrecL_
-- -- - � P - .fP rl�1' f � —
�u e. ate: _
Phone #:
?r ��
Official use only Do not w, iri this area, f be cvmp ed by city or town official
City or Town: PermitlLicense #
Issuing Authority (circle one):
-'I; Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspect
6. Other
Contact Person: Phone #-
SECTION 8 - CONSTRUCTION SERVICES ,
8.1 Licensed Construction S e rv �} Not Ap /
`
Name of License Holder: []'I 249 U
Llcense umbe
f A dva
ss Expir on Da e
Sli gnWture " I 11 Telephone
S. Re istered.Home im "rovementGOritractor .....- { 4 .. f ,.Y. ,., Not Applicable ❑
Company Name Regis ra ion Wumber
Ad f Expiratifon Da
s� Telephone
S ECTION 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_`. ,Iomeowners" 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 buildine permit.
As acting Construction Suuervisut quw presence on the job site will be required from time to time, during and „inn
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 r mances, ' s-CTeneral Laws- Annotated.
Homeowner Signature
8
Y ,
s
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
.New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or boors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks 10 Siding f0j Other [p]
Brief Desertion of Proposed -A r'-
Work: � ri L , -
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a " If.I ew h'viise.anc - or.ac[sl i rt.to existing ouslna` complete the fciliow,19A.
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms t
c. Is there a garage attached ? -�
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f Method of heating? 4� 5 Fireplaces or Woodstoves Number of each l
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 X No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
1. Septic Tank City Sewer Private well City water Supply
SECTION Ta: -OWNER AUTHORlZA770N - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUJ PERMIT
4 — as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
./k. L ( 110a ( 4 as Owner /Authorized
Agent here 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 penalties of perjury.
a e
Signature of Own gent Date
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
w W
Lot Size
Frontage
Setbacks Front
Side L : _ m R. ..r_ .._.r L: ;_^_ —. R:
Rear
Building Height
Bldg. Square Footage _ % , _.
Open Space Footage _ % - ...
(Lot area minus bldg & paved
p arking)
# of Parking Spaces -- --
Fill:
f w
_.�_
(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:;
L---1 .
IF YES: Was the permit recorded at the Registry of Deeds?
NO DO KNOW _0 YES
IF YES: enter Book = Page? ` and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do dny signs exist on the property? YES NO
IF YES, describe size, type and location:
Il bra t�iera � y prn�insarl'r angas to nr a _ihnns n signs i�tPn Qri - Fnr tliP'lirnoorty 7 YFS Q 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 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
M me ar B iril:66"
City of Northampton of %*
Building Department �i a�ygrt
212 Main Street S � A atiah s ff:
Room 100
Northampton, MA 0
phone 413 -1'240 Fax 413 - 587 -1272 Pao
arm
APPLICATION TO CONSTRUCT, 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
Map Lot Unit
`1
Zane `' Overlay District
EIm St District GB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record �p ]
p ., - l� c�
-- VA,
Name (Print) Current Mailing Address:
C7 2 L4
5--- Telephone
Signature
i
2. thorized A ent:
! Current Mailing ddre�s: /
F
Signal re Tel p one
SECTION 3 -:E (MATED CONSTRUCTION
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building(6) Building Permit' Fee
C
2. Electrical (b) Estimated Total -Cost of
Construction from 6
3. Plumbing Building Permit Fcc
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) "� . G Check Number
— _ 4
This Section FarOfficial'Use Onf
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings° ' Date
BP -2010-0701
'
COMMONWEALTH OF MASSACHUSETTS
,0�` CITY OF NORTHAMPTON
L -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: B uilding DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate�lorY BUILDING PERMIT
Permit # BP -2010 -0701
P =ect # _ _ __JS -2 010- 001043
F. st. Cost 1400.
Fee: $35. PERMISSION IS HEREBY GRANTED TO:
Const. Cl — Contractor: Contractor: License:
Use Grou ROBERT C GOULD 090940
Lot Size( sq ft.). _5445 Owner PETERSSON ROBERT T & SUZANNE S
Zoning: Rk( 1)L_kAj2 /) /WP Applicant: ROBERT C GOULD
AT. 32 WARD AVE
Applicaw, , Iddress: Phone: Insurance:
6 2 LYN 1;`, " Si (413) 531 -1391 0
GRAN B MAO i 033 ISSUED ON :21312010 0:00:00
TO PERFORM THE FOLLOWING WORK :STRIP & SHINGLE PORCH ROOF
POST T C SO IT IS VISIBLE FROM THE STREET
Inspector of Nlumhing 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.
Certific of O_ ccu pancy Signature:
FeeType: Date Paid: Amount:
Building 2/3/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo