17A-228 v
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CIMR 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 boles (before your). 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
S 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
<_ Die Commonwealth 01°!lv�assachuse�:s
- - Department of ind;asar-iaiAccidenrs
_-- c O,1Zce of lnl'estZgaZZOaZS
600 IYashing ton Street
Boston, 41-4 02111
rvx'n'.mass.g ov/dia
'Workers' Compensation Insurance Afrida-dt: Builders,'Contractors,,EIectricians;Piumbers
ADalicant information Please Print Legibly
"';`1M C (Business,%Omani:atiorL'Individual): _
ddr-SS:
Citti'/State/Zip: Phone r:
Are you an employer?Check the appropriate box: Type of project(required):
i.❑ I am a employer with 4• ❑ I am a general contractor and I 6 ❑New cons—auction
employees full and/or art-time).* have hired the sub-contractors
ye (Rill listed on the attached sheet. 7. ❑Remodeling
2.❑ I m a sole proprietor or partner-
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. employees an
have workers' 9 ❑Building addition
No workers' comp. insurance comp. insurance.:
re u,.r_d J1 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3 I am a homeowner doing alI work officers have exercised their 11.❑Plumbing repairs or additions
myself. [--N-o workers' comp_ right of exemption per_MGL 12.❑Roof repairs
insurance required.] ' c. 152, §1(4),and we have no
employees. [No workers' 13•71 Other
comp.insurance required.]
'Any applicant that checks box#1 must aiso ill out the sec:on below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
4conn-actors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities rave
employees. If the sub-contactors 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�i or Self-ins. Lic.T: 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 ofNIGL c. 152 can lead to the imposition ofcrimiTal penalties of
fine 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 may be forwarded to the Office of
Investizatiors of the DLz for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Date:
Phone 1
J jIcial use only. Do not wrire in this area,to be completed by city or town official
Citv or Town: Permit,License
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Insaeciflr
6. Otter
i
Phone
Corracr Person: �: j
4 `
SECTION 8-CONSTRUCTION SERVICES
E.1 Licensed Construction Superrsor: Not Applicable ❑
Name of License Holder:
License Number
�dcress Expiration Date
Signature Telephone
i.Redistered Home Imarovernerrt*:Gonisad or Not Applicable ❑
:omnanv Name Registration Number
.ddress Expiration Date
Telephone
ECTION 1:0-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,
fcrkers 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.
fined Affidavit Attached Yes....... ❑ No...... ❑ I
The current exemption for"homeowners"was extended to include Owner-occupiers Dweliinzs 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.C1l'IR 780. SLZth Edition Section 103.3.5.1.
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-vear period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building OEcial,on a form acceptable to the Building Official.that he/she shall be
responsible for all such work performed under the buildino 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 Iiable for person(s)
you hire to perform work for you under this permit.
The undersizned"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.
JHomeowner Signature 2
i
SECTION b-DESCRIPTION OF PROPOSED WORK(check all anolicabie)
New House F7 Addition Replacement Windows Alterations) C Roofilng
Or Doors
Accessory Bldg. EZ� Demolition New Signs [O] Decks Siding (p Other[=J �.
Brief Description of Proposed
Work:
-iteration of existing bedroom Yes No Addinc new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a if New Ftouso and or aii.cliuon to ez spina hous c.commete tfleyfoE[oinrina:
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 Wcodstoves Number of each
g. Energy Ccnserration Compliance. Masschecic Energy Compliance form attached?
h. Type of construction
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 AUTHORIZATION TCY.SE COMPCETEiTWFiEN1
OWNERS-AGENT OR CONTRACTOR APPLIES FOR SEIItQINC PERMIT
i as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized
Agent hereby declare that the statements and Inform ation on the foregoing application are true and accurate, to the best of my knowiedge
and belief.
Signed under the pairs and penalties of penury.
Pnnt Marne
j ..cnar_re:��wner,Ace�i -
Section 4. ZONING i 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
7
Fronta_e
... _...,_.._..._._
.
Setbacks Front
Side L:_ ._._..... R: L _._..__._ R
Rear
Building Height
Bldg. Square Footage _ _...._... __.._._ % _. .._ _.._......,
Open Space Footage %
(Lot area minus bldg&paved
Dancing)
#of Parking Spaces — -- -- --•-..-
(volume&Location] w _
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 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 Page and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 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 NO
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 NO
IF YES, then a Ncrthampton Storm Water Managemernf Perm itfrom the DPW is required.
Department use only,,
--; City of Northamp ton Status of Permit
V17\Building Department Curb Cut/Drrvdway Permit
��
�} —� 212 Main S#ree� SewerlSefrcfCva€lability
Room 100 EiVateclt%UUeltAvailability
,UN p 200E Ncfthlampton, M.'. 01060 Two Sets of Structural Flans
phone 43-58�-1240 Fa-413-r-87-1272 P1otfSiie Plans
CC Otljer Specify
�ApP-ICA-ridN_T&36C STRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Prooerty Address: This section to be completed by office
Prap Lot Unit
00 ' Ct>, tVLQe c �t�l,`� Zone Overlay District
Elrn 5t District Ce District
SECTION 2-PROPERTY OWNERS HIPIAUTHORIZED AGENT
2.1 Owner of Record:{
�C7�C C9�� » C 2(`s✓.r- t� 1_G._�..2 `j,C`�' -�c �r 31�2 c,
Name(Print) Current Mailing Address: ;�ry
LA k
=a ry c��2.. V�.L1�• Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit aoolicant
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+S) Check Number
This Section For Official Use 0nl
-Date
Building Permit Number. -Issued:
Signature:
_
Budding.Gommissione�//Inspector or ui dings Gate
File#BP-2009-0003
APPLICANT/CONTACT PERSON RIDEOUT SARAH '
ADDRESS/PHONE 105 LAKE ST FLORENCE (413)584-6796
PROPERTY LOCATION 105 LAKE ST
MAP 17A PARCEL 228 001 ZONE URB r
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: ERECT 10 X 12 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
NEW
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