31A-002 City of Northampton
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l V $`_' DEPARTMENT OF BUILDING INSPECTIONS `; I en
?�. 212 Main Street • Municipal Building `
✓ Northampton, MA 01060 ss; �t�
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 any 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 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
I, Ac-\ ., - 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 \ ` \----b
Address of work location
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SECTION 8-CONSTRUCTION SERVICES •
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Ho •
License Number
Address Expiration Date
Signature Telep•one
9 'Re• sfered.Home.Im:rovenient Go' actor�`.. , ,.�_, ,_. ._, , _�r. .__ z__... Not Applicable £
Company Name - Registration Number
Address Expiration Date
Tele.•one
. SECTIO, 10-WORKERS'.COMPENSATION INSURANCE AFFIDAVIT( 4.G.L:c:_152,§25C(6)) ,
•rkers Compensation Insurance affidavit must be completed and submitted •h this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes £ No £
$
1� .. Rome Owner Ege"mpt>lon•
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,St t,e a • Local Zoning Laws and State\f Massachusetts General La s Anno ated.
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Homeowner Signature. 441.
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The Commonwealth of Massachusetts
_ r Department of Industrial Accidents
II� Office of Investigations
rr_ 600 Washington Street
°!! �` Boston,MA 02111
s•°'.w www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information - i Please Print Legibly
Name (Business/Organi7ation/Individual): \ \
Address: \ -
City/State/Zip' �� � � i �V
p 1� Phone#: \�' � a�
Are you an employer?Check the appropriate box: Type of project(required): i7
1.0 I am a employer with 4. 0 I am a general contractor and I
6. 0 New 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. 0 Remodeling
ship and have.no.employees These subcontractors have. - .g. 0 Demolition r
working for me in any capacity. employees and have workers 9. Building addition
o workers'comp.insurance comp.insurance.$
e uired: 5. We are a corporation and its 14:0 Electrical repairs or additions
3. am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
yself. [No workers'comp. right of exemption'per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.0 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.
tContractors 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:
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 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 imprisonment; 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.
I do hereby cert u er the pains and penalties erjury that the information provided above 4 true and correct.
Signature: er
\� - Date: \\ L- - \'Th
Phone#: ' -- \ 37 �. -` —e.'---2— -\(--) - -
Official use only. Do not write in this area,to be completed by city or town o fcia.
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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
Contact Person: Phone#:
City of Northampton
`'° Massachusetts
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DEPARTMENT OF BUILDING INSPECTIONS ''1- tr 1, � `) , 212 Main Street • Municipal Building ..,.=
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LI , Northampton, MA 01060 r€'j1 4,o‘
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Electric, PL nb r , (-a i ■ ,ctions I
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SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS
Permit Fee: $25.00 Check #
PLEASE TYPE OR PRINT ALL INFORMATION
PROPERTY ADDRESS r)'T* \ \ (") -
1. Name of Applicant: \,(\Q ti-. _)t-,T. ONI\1'�
Address: J.-1D \�-)N. 'j_ / Telephone:
2. Owner of Property: lS (-- -""N\-3'^(-- -""N\-3'^..- ‘-- ..\-\Q"(\JIM.3Vs._ ��D
Address: o 'CL.----\1`--A
Telephone:
3. Status of Applicant: er Contractor
4. Type or Brand of Stove: b �)rt.� L, � — "" 5$ l•INv\
Contractor's Name: \,'- (e_ c � -'` `S`='�-S
Contractor's Address: 2) ` r.:'\\ C:Z' .\,„S\. �V\' "=' — s . �1►_ \A- OA ■
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Contractor's Phone: N-1- SC 442
Construction Supervisor's License Number: Expiration Date:
Home Improvement Contractor Registration Number: Expiration Date:
All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit
5. Certification: I hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: APPLICANT'S SIGNATURE
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DATE: \\\D_A\ ,7 HOMEOWNER'S SIGNATUR'Eti, ''I' �J�A \i'"
APPROVED
DATE: /0 0-3 BUILDING OFFICIAL
330 ELM ST BP-2014-0667
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A-002 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit# BP-2014-0667
Project# JS-2014-001144
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WESTERN MASS MASONS 133234
Lot Size(sq. ft.): 24001.56 Owner: SONN DONALD&SHANNON
Zoning:URB(100)/ Applicant: SONN DONALD & SHANNON
AT: 330 ELM ST
Applicant Address: Phone: Insurance:
330 ELM ST (413) 586-5407 ()
NORTHAMPTONMA01060 ISSUED ON:12/3/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WOODSTOVE
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 12/3/2013 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner