18C-073 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 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
iermits 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 tome.
Date
Address of work
location
4 '•
7
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• The Commonwealth ofMassachusetts
Department of Indus ACridents
Office of InivstigationS .
=LAD= 2 600 Washington Street
INIMIll• =MEI $.1.7
.'04 .F ■ril= Z Boston, MA 02111 .
www.mass crov/dia
- b
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information - Please Print Leg/H
. ,
i
Name (Businesi/Organiiation/Individual): gebt-r-e-tdo &b/w e
- - Address:, :;( East- •
Haftg, —>t - ,- . •
City/State/Zip: Eajt t ami,pkii 114 6 i 0 d • Phone.#: 1/3 - ..5 , ;Z7- 746- • -
i ,
Are you an employer? Check the appropriatehox: • •Type of project (required): •
employees (full and/or part-ti).* /
1. Eti I am a employer with / 4.. El I am a general contractor and I
l ' ' "on and
have hired the sub-contractors
6. E New c me
listed on the:attached Rem
2.0 I aam a Sole proprietor or partner-- sheet 7. 0 odeling
ship and have no loyees These sub-contractors have. -8. D D einblition
.:r
• working for me m any capacity . emiloyees wodcers ..- ..- •
9 tamildpaia.4ditioli
[-N w comp i nsurance • _ •compl..inturancel:. .- .
rtions
required.] .. - 5. 0 We are a corporation and its 10.0 Electrical repairs or adcr
,....,
3. o I am a homeowner dOing all work officers haVe4 ll
xereised their .
.1 11. Pluitibing repairs or additions
myself, [No workers' comp. • right Of exemption per MGL
12.0 Roof repairs . •
insurance required.] 1- ' • . : : c . . 152, § 1(4), and we have no •
employees: [No workers' r
• 13 Other
•
• : . - comp. insurance reqUired.j.
*My applicant -that checks box #1 must also fill out the section below showing their compensation policy information; •
1. Horaeownesi who submit this affidavit ineffmth' li they are doing all work and then hire outside Lon tors must submit anew affidavit indicating such.
Contractors that check this box mnstattached an adational iteet showing the name of the subcontractors and State. whetheror notthose-entities have • .
nmloyees. If the sub-contraitorshaie employees, they mustpravide waiters' comp policy number
.1 am an employer that is providing workers' compensation insurance for my einpleyees. Below is the a policyand job:site
information. . -
r d-
.
•
Insurance Company Name: -- it / r : . .
. . . ,
Po # or Self-ins. Lic. #: e-..5 4 (-& Z5 pi • / 0 i 1 Expiration Data: - ,.„i/o? 7»3
,01,4 „Le , 1 ;,,
Job Site Address: 717 47# /11b /7/ O/06,0 City/Statc/ZIP:' - ' . . '
Attach a copy of the workers' compensation policy declaration page•(shovving the policy number and expiration date).
Failure to secure coverage; as required rider Seetidii25AOfMGL•c: 152,eari lead to the iiiiiiiiiiirori ofciiiiiiriiiii of a
fine up to $1,500.00 and/or one-year imprisonzaent; as well as civil penalties in the form of; STOP WOBJEC-ORDER and a fine
of up to $250 00 a day against the 'violator Be advised'that a copy Of II* statement may be forwarded to
- i„,,H,..._
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170 ;ipert;iitlWolpirjtay .. 'ilrizi - ihiiiiotiiii;niir6 . 1.7;Siiie:iizii-Tbrr e 7 -7--
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i •s;n I • ( * A--- • ' - - --- --- - - ----- :---. ./;-..,?, ..-/„L
S i ') • . , ,
/4 6 f 1
. - ' - D ate- — • • ,
Phone 4: 4 — 5 - A 7 7 , l :3- • . • - -. . ' - : . T . . • . - - • .
. - OffiCial use only. Do not write in this' aria, to be completed by city Or toWnbfficifff
. , : .• .
City or Town: . "- Permit/License # ' ...._
Issuing Authority (circle one):
:1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electricaljnspector 5. Plumbing Inspector
6. Other .
• Contact Person: Phone #:.
• -
. • .
SECTION 8 -- CONSTRUCTION SERVICES 1
8.1 Licensed Construction Supervisor: �/� Not Applicable ❑
Name of License Holder : /J )/2 � O LLir
License Number
sf 1 / ne 114- o z7 99
Address Expiration Date
113-5, 7 _3
Signature Telephone 6 2 Z —
S. RttistendNHntt�e Improvement;.Ooritracrf $ ,f , �a o , g `x.,, g w Not Applicable ❑
13 rIt 04019
Company Name Registration Number
301+ � S� . / /. 1
Address f (� L' Expiration Date
/'
�ik3Tl ll1 l iN HA om27 Telephone 1 /3 7
—
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.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 buil 'ng permit.
Signed Affidavit Attached Yes No ❑
.,,.,.. + ;;W:xle kll on
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 E
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [Q Siding [❑] Other [D]
Brief Descp 'ption of Propoed ��
Work: 7"ri • -e / 1 i c / Q - AF ` L i_. �/ : t kC h/�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
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
40 a-04- AI t / , as Owner of the subject
property — -
hereby authorize 7 30b ' /1/491/(1-6
to act on my beha ,' in all matters relative to work authorized by this building permit application.
Signature of Own r Date
. 3 - 419 / /1,4'G' , as Owner /Authorized
Agent hereby declare 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 perjury.
Print N.1 e
Signature of Owner /Agent Date
y
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
i
Lot Size l ' I
Frontage
Setbacks Front
11,77 ..__ __.
Side L: R: L:'. R: ', _ _;
Rear = I � '- -- ----°'
Building Height I I ` S
I
Bldg. Square Footage [ 1 % 4
Open Space Footage %
(Lot area minus bldg & paved [ *Ti i„.; ? , I L„ .
parking)
# of Parking Spaces "° ' 1
Fill: ( — . _. -
(volume & Location) i
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! j and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
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 Q NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q 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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
ep
•
a ,�. A a �QM�' •em tl of � �. L
City of Northampton��
REQ v — --1 Building Department � r� r � x, 44
212 Main Street y 5 4
jU4 2 20`2 Room 100 ` :E
orthampton, MA 01060 +, 4-
- phone 413- 587 -1240 Fax 413 - 587 -1272
L- o60
DE-
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
6/id Map = Lot . ! Unit
A_/eYyi-ti /t ;bane Over la irD i strict
Eim St. District CB District
SECTION 2 — PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
W/ / /ic /Veil 7 '7'7 &4 A/c(7 /J /1/ /I4
Name (Prin9 r Current Mailing Addrgss 957
w Telephone �� T
Signature
2.2 Authorized Agent: _
&o /heck i East- kJJ, fecs -nji Al H4
Name Print) Current Mailing Addr s:
4/3 7- 7663
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed 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) -i I / i ( Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -1155
APPLICANT /CONTACT PERSON BOB THIBODO ROOFING & SIDING
ADDRESS/PHONE P 0 BOX 201 NORTHAMPTON (413) 527 -7663 Q
PROPERTY LOCATION 777 BRIDGE RD
MAP 18C PARCEL 073 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid It /009" f "°
Building Permit Filled out
Fee Paid
Typeof Construction: STRIP & SHINGLE ROOF
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 065699
3 sets of P / Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN RMATION 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
A - 1 ol .;• ,
4e , Z;-5/
re 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.
777 BRIDGE RD BP- 2012 -1155
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C - 073 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- 2012 -1155
Project # JS- 2012 - 001978
Est. Cost: $11000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 065699
Lot Size(sq. ft.): 23391.72 Owner: NOEL WILLIAM
Zoning: URB(100)/ Applicant: BOB THIBODO ROOFING & SIDING
AT: 777 BRIDGE RD
Applicant Address: Phone: Insurance:
P 0 BOX 201 (413) 527 -7663 ()
NORTHAMPTONMAO1061 ISSUED ON:6/25/2012 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 6/25/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck— Building Commissioner