32A-165 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
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 Industrial Aecidents •
Office of Investigations
t -- 7: - _- . 1-301.._- - = 2
‘ 600 Washington Street
..„,. =1-44......, ...7
: -Fgif— )6 Boston, MA 02111
1... -.=-...-:, - .
www.mass.gov/dia •
, •
.•
- Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers ...
Applicant Information Please Print Legiblv --.:
Name (Businesi/Organilation/Indivichin1):
Address: ,. - -
City/State/Zip: - Phone.#:
Are/0u an employer? Check the appropriate box: Type of project (required): 11'
1.0 I am a loyer with .,... 4. El I am a general contractor arui I
6. 0 New construction
have hired the sub-contractors
employees (full and/or part-time).*
listed on theattached sheet. 7. El R,emodeing
2.0 I am a sole proprietor or partner-
These sub-contractors have
ship ond have no ->tloyees 8. 0 Demblidon
enloyees_and have workers'
working for me in any capacity. 9: ElBuilding addititin
[No workers" comp. iesarance
requirect] .. 5. 0 We are a corporation and its 10.0 Electdcal repairs or additions
3. o I am a homeowner doing all work officers bavexercised their .
11.0 Plumbmg . repairs or adclitions
myself [No workers' comp. right Of exemption per MGL
120 Roof =pairs
insurance required] t s c. 152, *1(4), and we have no
13.0 er
employees. [No workers' Oth
comp. insurance reqUired.1 .
*Any applicant-that checks box #I must also fill out the section below showing their workers compensation policy infomution.
t Homeowneri who submit this afficlaVit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating Stiril
Contractors that rhi.r4r this box must attached an additional sheet showing the name of the subcontractors and state whether or notthose entities have
employees. If the sub-contractors Italie employe= they must provide their woricers' comp. policy nmnber.
I am an employer that is providing workers' compensation insurance for my einployees. Below is the policy and job site
information.
Insurance Company Name: 4cE U 5 o . .
- • , , ,,„ „
Policy # or Self-ins. Lic. #: C. q bl5.1 A I :0 Expiration Date: - / 9 ho
•
Job Site Address: (.0 5 NaLtAeti sr . City/State'Zip:4 0101, d
Attach a copy of the workers' compensation policy declaration page (showing the policy number and date).
Failure to secure coverage . as reqUired Mider Seetibii'25A 152 can lead to the inapeaitibri Of — alit:ling Penalties of a
fine up to 51,500.00 and/or one-year imprisonme4 as well as civil penalties in the form of a STOP WORKOMDER and a fine
of up to 5250.00 a day against the violator Be advised that a copy af this statement may be forwarded to the Offiee of
liffeiitioni of the DIA for iiiininde coverage ieriEeOli
'iky le ii.4;r thePains -an d p'eniali&i'ofp erjury that the infartnatiOnprOvidifirib a.±.711 _.
.
Signature: , - Date: • '
Phone ii:() 53o - ---- 1e) 3 (Ce(i) ( 58 - Ott L IC (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):
. I. Board of Health 2- Building Department 3. City/Town Clerk . 4. Electricalinspector 5. Plumbing Inspector
6. Other , c- .
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Constructi Supervisor / I Not Applicable 0
Name of License Holder : C( In K L t �1Q f r I/2 ✓ 73
e! r f G/rr - p 4)4 1 t L-e Vetfe I a Li e Number ~ 16
Address Expiration Date
e , `! *3 - - 2-763
Signat Telephone
g . ( , 3 w N ot Applicable
❑
8 ° ®
e_ .��,..:_ . u - ° � . row � � � � � ; '�,� w�� �„��� PP
•-. 4 ge. ► eb- yg
Com an Na e Regist
4c.» -e h £)4 K 4 ke..Ve_r-erlf- Address Expiration Date
Telephone 4117 ~33° - Z 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 ❑ No ❑
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 buildine 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
i %
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replaceme try Windows Alteration(s) ❑ Roofing ❑
Or Doors �j��
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [p] Other [p]
Brief Description of Proposed p rj t Q� �/ � J' �--
Work: t� e— 6 1(...e..-- F td `ii 0 ru9t atd `v c V''
Alteration of existing bedroom Yes _ NoL Adding new bedroom Yes , No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a id ine&i I i `f . t. dI till ! & o ; - t +.F1�]loiffia:
a. Use of building : One Family Two Family y Other
b. Number of rooms in each family unit: 6 3 Number of Bathrooms / / /
c. Is there a garage attached? Nte
l
d. Proposed Square footage of new construction. N 19 rte-- Dimensions
e. Number of stories? Z
f. Method of heating? (t; A-4) Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction tt. 1 ,% � ''--�
I Is construction within 100 ft. of wetlands? Yes Wells construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade t 'v +4
k. Will building conform to the Building and Zoning regulations? Ct. No .
I. Septic Tank City Sewer p.--- Private well City water Supply ___---------
SECTION la.- OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, C'i'.til. (' --) ' , as Owner of the subject
property d
hereby authorize /6 &..L . • 2 Ai -z 2.
to act on • - half, in all matters relative to work authorized by this building permit application.
31/1// O
Signatu • Owner Date
' . 6
1
1 , as Owner( orized
V en reby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
a elief.
Signed under the pains and penalties perjury.
ka.rv t l d `o
Print Name ■ 5 ` // - 4'
Signature of Own-r alb Date
F
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 i i . I i I
Frontage i L_.
Setbacks Front = i 1
Side L:1 i R:= L:7 R:
Rear ! I
Building Height = L__...i
Bldg. Square Footage 1 1 - 1 % 1 1 = [ 1
Open Space Footage %
I i
(Lot area minus bldg & paved 1 . 1 [- 7
parking)
# of Parking Spaces I l 1
Fill: 1
& Location) (volume i .
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 631.„,,, YES 0
1
IF YES, date issued:( i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Y — YES 0
IF YES: enter Book I Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 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 ® 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 1 t
IF YES, describe size, type and location: l f
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton - n `
Building Department 6
212 Main Street
Room 100 $
t �L` r s a — .
Northampton, MA 01060 e�
phone 413 - 587 -1240 Fax 413- 587 -1272 , ,1 x . ,,�
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION J N 4 20 0 w' i
This section to be completed tar office
1.1 Pro a Ad ress: 1 i i f - 0
6 3 a.
4 i :1'F, ➢ �{ i,3�1�
� l e. e-- Map t� --
Zone overlay Dist
Elm . St District':' CB
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
c Ji1 1 (oh,ZA,. S ..
Name (Print) Current Mailing Address:
'^� , -t1'3 t...1 .5 7oi
iI A.U` ` Telephone
Signatu WI
Auth .. sized nt: � t> 1<7 G.1r"�� 3 ` IE�- 5 C ( / -4 r Qt Re i
Name / 1,4 '' f Current Mailing Address: / /
s i g n. ) , 'el.' / ■INIIIIII
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 2/ie sl " .(, (a) Building Permit Fee
2. Electrical C./ (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) Check Number '13� ,) 'C r°
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature
eitc-/
---- 6 1 `1 IU
Building Commissioner/Inspector of Buildings
Date
v 3 HAWLBY ST BP- 2010 -1149
GIS #: COMMONWEALTH OF MASSACHUSETTS
ut:Block: 32A -165 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- 2010 -1149
Project # JS- 2010- 001685
Est. Cost: $2500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RANDAL ROBERTS 042573
Lot Size(sq. ft.): 5837.04 Owner: COHEN JILL
Zoning: URC(100)/ Applicant: RANDALL ROBERTS
AT: 63 HAWLEY ST
Applicant Address: Phone: Insurance:
321 RUSSELL ST (413) 530 -2703 () Workers
Compensation
HADLEYMA01035 ISSUED ON:6/17/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOW
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 6/17/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo