32C-095 (3) ' T
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 stru es. A
person who constructs more than one home in a two -year period shall not be co idered a
home owner."
The building department for the City of Northampton wants person(s) w i seek to use
the home owner exemption, to act as their own construction supervisor o be aware that
by doing so you become responsible for compliance with state bu ing codes and
regulations. The inspection process requires that the building dep.. u ent be called to
inspect work at various stages, u iclr inrihrde found. '+ + + • ore back
sonotube holes (before pour). a r ugh building inspection (b • ore work is
concealed), insulation inspection (i euuired) and a final b ilding inspection. The
building department requires these insp ions before the w. is concealed, failure to
secure these inspections can result in fai re to obtain , certificate of occupancy
un #il_ can-be e inspected:
If the homeowner hires other trades to perform , ork (; ectrical, plumbing & gas) the
homeowner will be responsible to make sure that be ades hired secure their proper
permits in conjunction to the building permit issue., : id that they get their required
inspections. Failure of the individual trades to se' e *emits and inspections as
required can DELAY the project until such ' I • as the pro: -r permits and inspections are
made
unde tand the above.
(Home owner /resident's signatur requesting exemption)
I will call to schedule all required bui ': mg mspec necessary for the bu ding permit
issued to me.
Date
Address of work
location � -
( I (
The Commonwealth of Massachusetts
__ Department of Industrial Accidents
. f Office bf Investigations
— 600 Washing
r ton Street
a � l Boston, MA 02111
te. ; �
, tom' , www.mass.gov /dia
Workers' Compensation InsuranPe Affidavit: Builders/ Contractors /ElectricianslPIumbers
Applicant Information Please Print Legibly •
/
Name (Business /Or anization/Individual): 1 0. ,e,1 r 0--c," /4-__C—,
Address: 0 7 v C t 1/16' <' J
City /St Type of ( /Zip: c,�i cY� ,1'l c Phone #: '�3 �""LO --�6 Y
Are yo an employer? Check t appro priate box: T (required):
)
4. I am a general contractor and I
1. I am a employer with g 6. ❑ New w construction
employees (full and/or part- time).* have hired the sub- contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.#
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner - doing alt -work - -- -- officers have exercised their i 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. ❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit 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 must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 0 a V -/ V 4'
Policy # or Self -ins. Lic. #: /9 I^ C 2 0 I J f Q 3 0 0 / 2O) Expiration Date: / 7 O
Job Site Address: 2/ ( CU h -2 , S / Pi L•' ith 4 2 fj Cit /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 and /or one- year - as well-as civil penalties -in- the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/do hereby certify un¢'� , , ins and penalt'es of perjury that the information provided ' bovJ true and correct.
t ` ' S t
Signature: d I ■ t Date: Phone #: _ •
1-- -
Official tise 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. Boar- d- a£- 1{ealth 2— Building Department 3. City/Town Clerk__4.F1ectrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : a u( r'S ft LfH `et" 662-7
License Numbe
Z /
A ress. / Expiration '•ate
( /3 - 2-4 - 7?
Si a cure ; Telephone
S. Re. late d Home" m ® roue Not Applicable ❑
(5
Company Name // � Registration Number
Z3 �' 0 « it--c
Addre s r Expiration Date
!l3
Telephone / 2 /ty2,, 26) //
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit • st be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildin• •ermit.
Signed Affidavit Attached Yes ! No
❑
nx
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 1083.5.1.
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 E] Addition 0 Replacement Windows Alteration(s) Q Roofing
I —� Or Doors ❑
r E
Acce?aory Bldg. ❑ Demolition New Si gi1S [C] Decks [1:::3 Siding [0j Other [G]
I
Brief Description of Proposed ' �, r ?Cry ,� �� e w do/ �'c �i
Work: 61 V e 7 Jh UU
Alteration of existing bedroom Yes No dding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a If New h ause.an ct ar,Additior" "t ` >Isifr ct<haits nit complefewthe.folttiwlril q:
a. Use of building " One Family Family Other
9 Y Y
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
A -- a77 e shy , as Owner of the subject
property /t-
hereby authorize 'J a l i,_ t. � a tt �L f
o act on m •ehalf, in all matters re • iork authoriz by this building permit a•plicati, .
> <'t
S'rt e of Ow er Date
� / - 7 — , as Owne Authoriz
—�
I, --/ -5 Q
Agent hereby declare that the statements an information on the foregoing application are true and accurate, to the best o my nowledge
and belief.
Signed u pains and penal . es of perjury.
Print Name ilk Ili i � (7
Si. - I Ag•nt '. �itiMIr
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
LotSize _ . ...._.. __ .... _. _._...__._._ ...___ i ......... ..__._ __..._ ._,.._.
Frontage
Setbacks Front _.
Side L: }_ R.,_.. _. L ._. _ R
Rear
Building Height
Bldg. Square Footage
Opcn Spacc Footagc 0/
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill: i € ..�
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 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 Page and /or Document #',
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for- the property ? YES I NO 0
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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
•
a� 014 # s a Oa. — 01 " � fi
City of Northampton , 4 A Rs
Budding Department • s`iiraayfe ` ,
212 Main Street s e3 i- 4 `
Room 100 ��Ava a iut� ` �, �, 1
Northampton, MA 01060 �� t t§t�,ck a Pia 7 ,. ,
phone 413- 587 -1240 Fax 413- 587 -1272 ` �h 5 ,
i
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMO • i
I7 1 op •' • V i ' ', , T— ING ,
a
lil�E 1„,f'
SECTION 1 - SITE INFORMATION - ` 2 0 "' 0 9
C1{0?rS
7
Thi" M to be completed by o r e
1.1 Property Address: At1G _
Map .. ,,.- m 1 C �'G {_ o Unit
2 � Z ' t
° � 6 �`
Zone- @v "delay , District
EIm S£ District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: /c4 el f S/ ac: / R- 6 1 —C; '7
'2. 2— L d - if 1— Kt M .14-
- (9.4----1675 „,„.._
Name (P 'nt) / ` / � Current Mailing Address:
,_ ' f f ' L Telephone
ign : ture
2.2 Authorized Agent:, 7 - 7, ,
Name (Print) e"'"") ! Current Mailing Address:
- ___. ` y t3 -20 - - /.G t( v
S' .n. ure Telephone
TION 3 - ' TIMATED CONSTRUCTIO COSTS / 7 0 a O r 0
item Estimated Cost (Doil�/) .to -be / Official Use Only
completed b .ermit ..licant
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 27 ?? *4)5--
,
• 7- "This- Section ""For Offidal - Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
ST BP- 2010 -0181
GIS #: COMMONWEALTH OF MASSACHUSETTS
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 -0181
Project # JS- 2010- 000226
Est. Cost: $17000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WEATHERPROOF CONSTRUCTIONINC 062833
Lot Size(sq. ft.): 15855.84 Owner: HESTON KARL ROBERT
Zoning: URC(100)/ Applicant: WEATHERPROOF CONSTRUCTIONINC
AT: 22 CONZ ST
Applicant Address: Phone: Insurance:
23 -2 TREEHOUSE CIR (413) 203 -1642 () WC
EASTHAM PTON MA01027 ISSUED ON: 8/17/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE WITH METAL 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 8/17/2009 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo