38B-164 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- ekemption, act as their own donstractrgn 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 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 i 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
�ermits 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
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
T
• s
77ie Commonwealth of Massachusetts
Department of Industrial Accidents "
Office of Investigations
600 Washington Street
Boston, MA 02111
•� y www.mass gov/dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Piumb:ers
Applicant Information Please Print LeigbIy
Name ( Business /orgmizadon/Individual): . beh bf 6
Address: 3,2 o
City /State(Zip: &jah .MA 6.6QZ Phone. #: 41z - L;- 7
Are Ton an employer ?.Check the appropriate'box: Type of project (required):.
1. QI am a employer with 4.. ❑ I am a general contractor and I 6. New construction,
enployees (fall and/or part time).# have hired the sub contractors
2.. ❑ I am a sole proprietor or partner- listed on -the attached sheet 7. ❑ Re
• ship ;Md have no en;loyees These sub - contractors have S. ❑' Demolition
working for me m as �Ioyees.and Izave workers'
rkmg y capacity. 9❑ l ut3dmg a d non
[No wo comp- m strraxweC - ta3mp.
re cd 5. ❑. We are a corporation and its 10.[] Electrical repass or additions
v
h
ffi
ocers aexercised their 11. Plumb' r epairs or additions
3. ❑ I am a homeowner doing an work •r • ❑ mg
myself- [No workers' comp.
right of exemptzori per MGL 12: [2/Roof repairs
insurance required.] t c. 152, §1(4), and'we have no
employees: [No workers' 13:0 Other
comp_ Insurance r
'Any applicant Shat checks -box #I-must,also fin out the section below.showing theawod=s'- convcnsad- policy information
t Homeowners who submit this affcdavit.indicating they are doing an work and then. hire outside con=ctots must submit anew affidavit indicating such.
=Contractors that check this box must.attached an additional sheet showing the name.of the subcontractors arid state whed=-or notthose-entities have
employees. Zthe sub - contractors have em pmyces, dwy must.plvvide flicir aim.' comp-.Policy numb
f am an employer that isproviding workers' compensation insurance for. my employees Belo_ w is thepolicy andjob site
information.
Insurance Company Name:
Policy # or ins. Lic. # -S � r U6 y � � 1'� , Expiration Date:
Job Site Address: ,. City /StafelZip: l�l� .- ff 1 4 .0 1066)
Attach a copy of the workers." compensation . policy declaration page'(showing the pgliq number and _ex _iration date).
Failure to' secare Co as r -
ge equn-ed under Sectcon`25F.; of MGL c: TSZ eau lead to the mzposition o penalties of a
fine up to $1,500.00 and/or one -year impr sonment;' as well as civil .penalties in the form of ;t STOP WF R -QRDBR and a fine
of up to $250.00 a -day against the violator. Be advised that a copy of this statement maybe forwarded to t O.ffi of
_av sa sal ons ofthe bIA for insurance coverazev 6HRcatfon
Ido hereby' card thepains andpenalties ofpm*y'ad the inforourdonproviderinbmv BL rue_eir '
Signature• . bate• .. C!
Phone 4:
: Official use only. Do not write in this area, to be completed by city or town'oazd L
City or Town: Permit/Llcense #
Issuing Authority (circle one):
J. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 -- CONSTRUCTION SERVICES
8.1 Licensed Construction Supe f Not Applicab ❑
Name of License Holder
License Number
Address Expiration Date
a (0-3
Signature Telephone
9. ltectistered Home:lrridro�ement:Contracttir , . w. F , ._ ..: s.._ vu: _ �.. a Not Applicable ❑
� :
I
Com an Name , Registrati Number
Address Expiration Date
Telephon � r t
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 building permit.
Signed 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. 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 buildine 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
N s
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition [] Replacement Windows Alteration(s) ED Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [M Siding [0] Other [O]
Brief Descrip of Proposed
Work: A � n
� J
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
� �` '* 'vim � 3 . � z
Ba If'Rte�ly t>Ia�t�se afidWac�d olfi_n to exi5tma toitisana t�rrlplefe the o(Cciwllria
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 7a OWNER AUTHORIZATION - TO BE COMPLETED W HEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize
to act op y'behaIf, in all ma ers relative to work authorized by this building permit application.
Signitu_4 of Ownert Date
I, b 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 ains,and penalties of perjury.
a h �®d
Pri Name
f® Z
Sign ture of Owner Agent Date
� f
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 Depirtment
Lot Size
Frontage
Setbacks Front
Side L: R __ L. R.
Rear
Building Height --
Bldg. Square Footage — — 1 --- %-
3 .... ..............
Open Space Footage %
(Lot area minus bldg & paved x
p arkin g)
# of Parking Spaces
Fill:
volume & Location
s` I
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT K 0 YES 0
IF YES: enter Boo Page 1 and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , 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 Q NO
IF YES, describe size, type and location:
i
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.
RECEIVED e
ity of Northampton �� ������3
uilding Department .��;
212 Main Street
Room 100
N hampton, MA 01060
DEPT of 9 UlNG INSPECULM
pppr}ap�ApTON 4 587 -1240 Fax 413 - 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION -
This section to be completed by office
1.1 Property Address
Map ° . Lot Unit
Zone OverfayDistd
Eart St Distract ' CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
dA 114
M Current Mailing Address:
wi - Telephone 4 - --6S-1-1 - J� 0 j
Signature
2.2 Authorized Agent:
ieJ�,,
Name (Print) Current Mail�Address: �
2z� ..� X13 - -)
Signa ure ' Telephone
SECTION 3 - 'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Bu lid! ng Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = 0 + 2 + 3 ZI Check Number
This Section For Official Use Onl
Date
Building Permit Number. Issued
Signature:
Building Commissioner /Inspector of Buildings Date
r
24 FORT ST BP- 2012 -0423
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc 38B - 164 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category ROOF BUILDING PERMIT
Permit # BP- 2012 -0423
Project # JS -2012- 000667
Est. Cost: $5000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 065699
Lot Size(sq. ft.): 10062.36 Owner: AHEARN MICHAEL J JR & PATRICIA
Zoning: URB(100)/ Applicant: BOB THIBODO ROOFING & SIDING
AT. 24 FORT ST
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527 -7663 WC
NORTHAMPTONMA01061 ISSUED ON :1012512011 0:00:00
TO PERFORM THE FOLLOWING WORK.- & 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 10/25/20110:00 :00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner