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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, act as their own °construetion 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 buildina (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'insected.
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
h 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
1 5.
. Z. . •
• . • The Commonwealth opfassachusetts
• Department of Industrial Accidents . '
Office o [Investigations
• 600 Washington Street 1 n
...-
Boston, MA 02111
.
"......,,, , www.mass.gov/cha
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name pusineseorganizationfindividp.D: --) i "/ / irk,
,----- .
• • Address: o ld 3 --- AioyeIlA
City/State/Zip: t, de e t E - C -e fit At Phone.#:
Are you an employer?. Check the appropriate box: • • Type of project (required):
1.0 I am a employer with • 4• 0 I am a general contractor ancl I 6.. 1...) ■---. N —
ew construction
emplriyees ilidlOr plitztiniCe).* haw hired gle - stth -e m itraeters
2. I am a sole proprietor or partner- listed on the attached sheet 7. 0 R.emodeling
ship have no employees These sub-contractors have- g 0 Demolition
working for me in any capacity. employees and have workers
9. 0 Building addition
[No workers' comp. insurance cnnaP. insurance-. - , Electncal repairs or additions . .
requ . • 5. 0 We are a corporation and its
10.11
S
3.0 I am a homeowner doing all work officers havelxercised their • 11.0 Plumbing repairs or additions
myself [No workers' c d m p. right of exemption per MGL 12.0 Roof repairs
insurance requir' ed.] t . c. 152, §1(4), and we have no
employees. [No workers' 13 -U Other
' - - comp. insurance required.1 .
*Any applicant that checIts box #1 must also fill out the section below showing their workers' compensation policy infomation. " •
t Homeowners who submit this affidairit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1 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 must provide their workers' comp. policy number. .
Jam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. . • • Insurance Company Name: • . .
Policy # or Self-ins. Lie. tfr: Expiration Date:'
Job 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 aral/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $25000 a day against the violator. Be advised that a copy of this statement may be forwarded to the Offibe of
Investigations of the DIA for insurance coverage verification.
Iilo hereby certi nder the , alas an penalties of perjury that the information provided above is tru and correct
• • ' de
Signature-
- •• , 'Date: . l / / • . •
Phone ti: c..// - ,, , , 2 1 0 d - ----- t i, ..r •
• • COffityicotair Town only. . • Permit/License #
y. Do not write in this area, to be completed by city or town official
Issuing Authority (circle one):
• .1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical,Inspector 5. Plumbing Inspector
6. Other t- •
Contact Person: • Phone #:
1
,
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. / Not Applicable ❑
Name of License Holder : fit e. r1 /
License Number t
• Addre � Expiration p
Signatu !( `
l am" /S. A/ 4 ���
, Telephone
9. Renistered Home Improvement Contractor. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
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 of the building permit
Signed Affidavit Attached Yes ❑ No ❑
11. - Home Owner Exemption
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 ender 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, von 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
/
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I
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----_________________............................___
•
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition rZt Replacement Windows Alteration(s) ❑ Roofing El
Or Doors [�
Accessory Bldg. ❑ Demolition ❑ New Signs [a] Decks [El Siding [CI] Other [Li)
Brief Description of Proposed l
Work: Ct dt,� 7 Lt O �� ` K f � -L ct ` `G � e Cte Se
Ai 6
Alteration of a fisting bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
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
i,
l " r ` . , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit a i ion.
Signature nn
re of Date
€ ` �` , 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 pains and penalties of perjury.
T " /1,4-ire
Print Name 7///
Signature of Owner? / 1r! Date
Section 4. ZONING Alt 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 /; frri
Frontage � ' 1 1577
Setbacks Front h
Side L: J R L: ! i
Rear
Building Height
Bldg. Square Footage : a ( ' O ' % (f 7 0 �y
Open Space Footage ' 7 yik7 % 7 7o ( 7 3 }
l q
(Lot area minus bldg & paved / (
parking) ( / -
# of Parking Spaces 6 G7
Fill: /
(volume & Location)! -
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW ® YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ' DONT KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 , 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 O NO O
IF YES, describe size, type and location:
E Will the construction activity disturb ( ring. grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO f j
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
t
L
• Department use only
II
City of Northampton Status of Permit
• Building Department Curb Cut/Driveway Permit
5 0 212 Main Street Sewer /Septic Availability
Room 100 Water/VVell Availability
ry ampton, MA 01060 Two Sets of Structural Plans
• • - 4i3- 587 -1240 Fax 413 -587 -1272 Plot/Site Plans
-. • * -- Other Specify
pecify
I APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: __,i
This section to be completed by office
7 it f f i ' t c .1J S I Map Lot Unit
f
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
id s crT inn , �t < 9I g. ,mac, e rte , .c - i •e-' _=
Name (Print) Current Maw ti ,.rito ,_ �`
Signature Telephone ' r / S J J• / 6 rY
As s
2.2 Authorized /Went:
(y(
T ,„ ,� /I 4-e e ;-7-<,,/ .i 3 i t, ., ,vc 7 C -, 0 :7 — y f ,? et <7 - E '.
Name (P ' t) Current Making Address:
z:// 7 6 a �- C,
Signet Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS i
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building f � .0., e ' (a) Building Permit Fee
2. Electrical „ 1 - ) (b) Estimated Total Cost of
Construction from (6)
3. Plumbing ,S -) C+ ea' Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) - ' L' �,> Check Number /475 I�
his Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/lnspector of Buildings Date
File # BP- 2012 -0007 ? III �,f3 0 I� I ` OJT 9�
V
ek AAJ I
APPLICANT /CONTACT PERSON JAMES HARRITY
ADDRESS/PHONE 225 NONOTUCK ST FLORENCE (413) 210 -5256 O
PROPERTY LOCATION 47 UNION ST
MAP 32A PARCEL 068 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out >!� v% / 9 0 Fee Paid /(p
Tvpeof Construction: CONSTRUCT 14 X 20 ADDITION
New Construction
Non Structural interior renovations
Addition to Existin&
Accessory Structure
Building Plans Included:
Owner/ Statement or License 052260
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
D • molition Delay
,� 7-- �7
Sit . 1 e 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.
F
47 UNION ST BP- 2012 -0007
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 068 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit # BP- 2012 -0007
Project # JS- 2011- 001778
Est. Cost: $23000.00
Fee: $148.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES HARRITY 052260
Lot Size(sq. ft.): 10541.52 Owner: WADE ROBERT N & AUDREY S
Zoning: URC(100)/ Applicant: JAMES HARRITY
AT: 47 UNION ST
Applicant Address: Phone: Insurance:
225 NONOTUCK ST (413) 210 -5256 0
FLORENCEMA01062 ISSUED ON: 7/8/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 14 X 20 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:
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 7/8/2011 0:00:00 $148.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner