35-133 DOME OWNER EXERTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 7800va 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
permits in conjunction to the building permit issued, and that they get their rewired
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. V
Date
Address of work
location
The Commonwea%tIt of_Ilassachuse:rs
x Deparrmenr of Inadzcsrrial.4cciden:s
0,l ce of ; vesri�aria.F�s
600 IVashingtan Streer
— Boson, LI_? 021-71
nww.mass.-ov1dia
tiyorkers' Compensation Insurance Affidavit: Builde rs/Contractors,TIectricians;Tlurrbers
Az;l7licant information Please Print Legibly
�'a171C; �,'Business,�Or�anizanorv'Individua:): �✓'l� _
Address:
City/State/Zip: Phone
7
Are you an employer'Check the appropriate box: Tope of project(required):
1.❑ I am a employer with �• ❑ I am a general contractor and I
empl full and/or par-time).* have hired the sub-contractors 6- ❑New consuuction
2. am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in an capacity. employees and have workers'
Y ca P 9. ❑Building addition
[-,\o workers' comp: insurance comp.insurance.+
required.] 5- ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.7 Plumbing repairs or additions
myself. [L'o workers' comp. right of exemption per VIGL 12.7 Roof repairs
insurance required-] ' c. 152, §1(4),and we have no
employees. [1 o workers' 13.7 Other
comp.insurance required.]
`.Any applicant that checks box=1 must also:ill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors rwst submit a new affidavit indicating such-
,Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and sate whether. or not these entities'rave
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 thepolicy and job site
inform ation.
insurance Company dame:
Policv``or Self-ins.Lic. r: 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
tine up to S 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 5250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DL,' for insurance coverage verification.
I do hereby certi under the pains and p es ofperjury that the information provided above is true and correct.
Signature: Date:
Phone
0,'j cial use only. Igo not write in this area, to be completed by city or town ojjtciaL
Cin7 or Town: Permit/License 7
Issuing Authority(circle one):
1.Bcard of Fealty 2.Building Department 3. Ci s"Town Clerk 4'.Electrical Inspector 5. Plumbing Inspector
1 6. Ot her
i Contra Person: Phone
SECTION 8-CONSTRUCTION SERVICES
Licensed Construction Suoeri;scr• � Not Applicable ❑ I
Name of License Helder
License Number
;deress Expiration Date
signature Telephone
i.Rectistered Homm tmprovernerit Cants Not Applicable ❑
s ,.r± .._. .. .,.,_. . .
:omoanv N / Registration Number
.ddress ��—�"— Expiration Date
Telephone G��1
ECTJON 1.0-WORKERS'COMPENSATION INSURANCE AFFIDAVIT 4M.G.L.o, 152,
lorkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit.
cried Affidavit Attached Yes....... ❑ No...... ❑
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.CAIR 780. Siith Edition Section 103.35.1.
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-vear 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 buildinZ permit.
As actin-ConstructionConstrnetion Supervisor your presence on the job site will be required from time to tune,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 Iiable for person(s)
you hire to perform work for you under this permit.
The undersimed"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoninz Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
M �
SECTION ION 5-DESCRIPTION OF PROPOSPD WORK fcheck all an
olicabie)
New house Addition Replacement Windows Alterations) I Roofing
Or Doors 0
FNumber sory Bldg. ❑ Demolition ❑ New Signs [p] Decks jL] Siding[p; Other
Description of Proposed '
ion of existing bedroom Ye No Adding new bedroom Yes No
d Narrative Renovating unfinished basement Yes No
ttached Roil -Sheet
ew hbusi~err 3 ar addiiiori'to exis#inct hau'siiici.cornatete,th�fa(Foinrina
e of building: One Family Two Family Other
mber of rooms in each family unit: Number of Bathrooms
ere a garage attached?
d- Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Weodstoves 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 A1ITHORIZA4T10N-.TO BE_GOMPf ETED VYHEN
OWNERS>AGcNT QR CONTRACTOR APPLIES EQR BUItt7iNCxP1=RM1T
I,
prcpe as Owner of the subject
r<y'
hereby authorize
to act on my behalf, in all m rs relative c crk authorized by this building permit application.
Signature of Owner Date
as Owner/Author"zed
P.gent^Era y eciar that the statemenT_ d in,crmation on the foregoing application are true and accurate, to the best of my knowledge
and belief-
Sicced ur er the pairs and penalties of perjury. I
P int i,Il- e
S�cr- f�wrer/A9e�t mate j
~ .
�
`
Section 4. ZONING ALL Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existinz Proposed ReqUiTed by Zoning
TTis colunin to be f7illed in by
Building Department
OT-iz-
Setbacks LFront
Re
Bldg- Square Footage
Open Space Footage %
(Lot area minus bidg&paved ........
#of ParkinL7 Spaces
A- Has aSpeciai Permit/Yariance/Finding ever been issued for/on the site?
�
~\ �
NO \_v��� DON7KNOW \�/ ~�YES t~�
|F YES, date issued
z '
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0
DONTKMOYY 0 YES
IF YES: enter Book Page and/or Document#| �
B. Does the site contain a brook, body of water orwetlands? NO 0 DONTKNOYY 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobeobtaned �-� Obtained v—\ Date' `�� ' \~� '
0 NO 0[. Do any
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 0
IF YES, describe size' type and location:
E. Will the construction activity disturb( hnQ.grading excavation, orfi||ing)over 1 acre orisit part ofaconnnonplan
that will disturb over 1acre? YES � ) NO � )
�� ��
|F YES,then a Northampton 8Go-��V0afe-r'M�����hfpennit from the DPW is required
Department use only
City of Northampton Status of PermFf:
- ,Building Department Curb Cut/Driveway Permit,
212 Main Street Sewer/SeaticAvailabiiity
Room 100 Water/We It.Availability
N&thampton, MA. 01060 TWO Sets of Structural Plans
Q
p�' tte 413-587-1240 Fax 413-587-1272 Plot/Site Plans
I Other Specify
a
APPUCAT ON VO qST ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECT t=SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map Lot Unit
Zone Overlay District
Elrri St District CIS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nalilgaon nt) �^ Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
�7
Sig re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item 5 ated Cost(Dollars)to be Official Use Only
oleted by permit aoolicant
1. Building Building'Permlt Fes
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
This Section For OfficiatUse Only
Date
Building Permit Number Issued:
Signature:
Building Commissioner//Inspe—ocor .uioings ate
BP-2008-1081
G-IS#: 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-2008-1081
Project# JS-2008-001598
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: James Roberts 117154
Lot Size(sq. ft.): 9452.52 Owner: GROVER FRANCIS
Zoning SR Applicant: James Roberts
AT. 8 WESTWOOD TERR
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON:61312008 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & 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 6/3/2008 0:00:00 $25.003235
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo