32A-213 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 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 backfdl),
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
•ermits 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 Accidents - ,
it ►.= 5 Office of Investigations '
=�4�= 600 Washington Street
I _"14 a
Boston, MA 021I1
,'. " " www.massgov /dia .
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Orgaaization/Individnal):, �- (
Address: —,,o ' F i( el ...i . • / r
City /State/Zip: j J ' Phone. #: 2 7 .— t
Are you an employer? Cheek the appropriatebox: • . Type of project (required) : /,
1. I am a loer with 4. 0 I am a general contractor and I
Y 6. 0 New construction
e ,.,• Ioyees (full and/or part-time).* have hired the sub- contractors
2.10 I ant a 'sole proprietor or partner- listed . on the attached sheet 7. 0 Remodeling
ship and have *_+;o• e.wIoyees These sub - contractors have .8. ❑ Demolition
wo rkui any for m an capacity elo workers' 9 $ aeon
[ ,
workers' comp. insurance _ comp. ,,s -n s.. - II ... .
ed 5. We are a corporation and its 10.0 Electrical repairs or additions
re
j ffi hv ci
officers aexersed their • 11. - Plunbm repairs 3.0 I am a homeowner doing ill work r : ❑ g or additions •
myself To workers' comp. - right of exemption per MGL 12:0. Roof repairs •
insurance required:3 t • c. 152, §1(4), and we have no -
employees: [No workers' - 13.0 either
{ comp. insurance reguiired.). I
*Any applicant-that checks box #1 must also fill out the section below showing theirwvot]aexs'-cornpensation policy information: .
t Homeowners who submit this affidavit: indicating they are doing all work and then hire outside contactors must submit anew affidavit indicating such.
Contractors that check this box mustatfached an additional sheet showing the name of the sob:- contractors and state whether or not thoseemties have
employees. If the sub- contracto s have employers, they must provide their workers' comp. policy number.
lam an employer that isproviding workers' compensation insurance for my employees Below is 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•(showing the policy number and expiration date).
Failure to secure coverage:as required under.Secti ii 25AofMGL c 152 san lead to the imposition ofcrimmalpenalties 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 £pie
of up to S250.00 a day against the violator Be advised that a copy of this statement may be forwarded to the O.ffi'ce of
Investisations ofthe DIA for uisurance' coverage v exitzcat<on. ,., __=,_....—.....
Ido: hereby�,certrnfy der the : and enalties ofperjury that the cnformatinnprovidedlrhovp _andcnrr '
Sienature: r' Da c if
// ....._ ,
Phone ii: ..
.. 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):
:1. Board of Health 2. Building Department 3. City/Town Clerk . 4. Electrical Inspector 5. Plumbing Inspector
6.Other
JJ Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su - rvisor: Not Applicable ❑
Name of License Holder :
c ' 0/
License Number
S eK
Address � Var-11
Ex piration Date
v
Signature Telephone
5)7
9 % 4 ter. itHortfeimprof emei t eiiiiifraCte , i ° z _. : , 2G z,r.,< l(v;I . _ .F . , Not Applicable ❑
raj Company Name / Registratio Num er
/VC/E./ Address / Expiration Date
Telephone ' 3 — 3
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (IN,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. - FiHome Ow ei Exem
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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors I]
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C7 Siding [D] Other [0]
Brief Description of Prop -c J.
Work: V" A �e `-.
Alteration of existing bedroom Yes No Addin ew bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa, if kiiiv ifolise a nd or 'ddifi i, t04XI find .h±)is roc &itri le a ttii.f 01lOWi n:
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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ' 7 - 1-'21�1-� -t/ , as Owner of the subject
property
hereby authorize ' i1& ./. f
to act on my behalf, in all ma *- relative to wo authorized by this building permit application.
/ /i/ L C�
. / j
Sign :Ire of Owner T Date
■
t
I ° _■ , as Owner /Authorized
Agent hereby 'clare 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 perju
1 s ic 0
Print Name '' r —7
Signa s Owner /Agent Date
1 .
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 _§ L - 1
Frontage i _ _____
Setbacks Front i
Side Li "_. R: L:! R:' __ Li
Rear __
Building Height 1 1 j 1 m
Bldg. Square Footage Erni t % j ,
Open Space Footage %
(Lot area minus bldg & paved
parking)
# of Parking Spaces i
Fill: 1 1 .� -...�� € m..®�...
o
(volume & Location) --
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book P age l and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES i
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 0
IF YES, describe size, type and location: 1 }
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q
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 Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
1
4 Itt t4 ue� y ' S . n �
GG N7 i 4 City of Northampton �
r � ` Building Department r g 1�
> ` 212 Main Street , a-- - 4 ,-, , , ..1 , - . . � , , $a doi: - + � 1; '
Room 100 ` :0, �,
o de Nhampton, MA 01060 ,
` one 413 - 587 -1240 Fax 413 - 587 -1272 E
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
j D4 Unit
L // / /'���
4 - - 'e Zone Overlay District
" f Etm St District . CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of - _ ord:
` � 1
Nam - P ••t) T Current Mailing Address:
/— V� - Telephone
Signa re '
2.2 Authorize. A•ent: ----
■ L�A�a 4/ Z�'
Name (Print , Current Mailing Address:
--4:3 r 5 7� �?
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
mpleted by permit applicant
1. Building (a) Building Permit Fee
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) Check Number 6 i2 0 , 5
This Sect For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
29 BUTLER PL BP-2011-1005
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 213 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP- 2011 -1005
Project # JS-2011-001635
Est. Cost: $15000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES ROBERTS 99404
Lot Size(sq. ft.): 10193.04 Owner: JASINSKI EDWARD & STEPHEN P JASINSKI
Zoning: URC(100)/ Applicant: JAMES ROBERTS
AT: 29 BUTLER PL
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527 -6078
W ESTHAM PTO N MA01027 ISSUED ON: 6/3/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: STRI P & SHINGLE ROOF
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 6/3/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner