24A-098 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 fondly
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
1, 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
, .
. ,
. The Commonwealth oftlfassachusetts
-...=-.2,---- Department of Industrial Acldents
p ik .......„=.... m
1,07. r Office of Investig,ations
600 Washington Street
Boston, MA 02111 .
www.mass.gov/dia
■ 'a ' •
, • • .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information •
Please Print Legiblv • :::
Name (Businesi/Organization/IndivirIn4): _ ,,,,, "Ina % v ,
•-..::::
, .
k
• Ackiressvi\ 0,R 5, 5
City/State/Zip: -e )2N \ -Itt.rN Phone.#: _.3')-- ---.) ko (
Are an employer? Check the approp telox: • . •Type of project (required): I
• 1.2 I am a employer with \ 4.. 0 I am a general contractor and I 6 ..
. 0 New construction
have hired the sub-contractors
employees (full and/or part-time).
listed on the:atta.ched sheet 7. 0 lemode/ing
2...0 I aril a sole proprietor or partner-
. ship and. have no, zloyefs.. These sub-contractors have -8. 0 De:iodation • .
wor f me i any capacity eingoyee.s. wOrkers' . - • .., 9 fl-B ..
: uildifig - aairdoii
r& 10.0 liectrical repairs or additions
r _..., Flirt7c ' • •
• 5. 0 We are a corporation and its
•
3. U I am a homeowner doing all work officers hair 4xeraised their .
11. Qi fnmbm g repairs or additions
myself [No workers' comp. • right of exemption per MGL 1221 Roof repairs
insurance revired f . . . 4 a ers no • 110 Other
' - • • • comp. insurance reqUized.l. - . • . .
*Any applicant lhat checks box #1 must also fill out the section below-showing theirwodoers' cornpensation policy informatiOn: -7 .
. ,
t Homeownera who submit this affidaVitinfficating they are doing all work and then hire outside contractors must submit' anew affidavit indicating such.
IContractors that check this box =staunched an arkfitional sheet showing the name of the sub:contractors and Site whether or notthoseentities have
employees. lithe sith-ccaitaib?rshalie emp]oye:a, they mistprovide their wOrkers comp poffey number.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policyand job
information. .
Insurance .
*v.....
C.ompaivN=2;A rN.IZ_V■rclnr"
\\ .c .
,
Policy # or Self-MS. Lic. #: kc S Co t) C./ 0 4-5 'N' 4, 0 1 k Expiration Date: - ' '
-• -.N)e' ,—) Cs---.• 4'v S A...;.... .,-
Job Site Address: \ ..) \._ ) x 4_ S - \ 3 • ' City/State/Zip :' - C I. \ - (D ( \
Attach a copy of the workers' compensation policy declaration page the policy nuinber andexpiration date).
. , _ . .._
• • .
Failure to secure coverage as required 'under Settibil25A•OfM GL• c 02 Can' lead to the iinPaiiijiiri Ofeiliaing penalties of a
fine Op to S1,500.00 and/or one-year implisonm* as well as civil Penalties in the form of a STOP WORK-OP:DER and a fine
of up to $250.00 a day against the Be advised That a copy of this statement may be tbe.Oitce:of J.
Eireltieitions Cif the DIX for'iiii Ciiiiiiiiiialtalkii: . . -',...., . :;., _. -7:::: - ,..., _..,.. , . ;,._ „
_ tiro lrer rt ;ter the P auzs : an I; I pen aesolperjuryiltal the hifr;rntationprovid is tahavektirg_Unri-Pri '
Si* . -lure': ._._1 W . A. WIS... ' 1 . D . 11 "-- ..--- - . • ,
....- —
•
Phone #: S - , . - . . .
. - Official use only. Do not write in this area, to be completed by city o r towneiciaL . ., .
City or Town:
P6xmit/License #
Issuing Authority (circle one):
"- '
.. .
;1 th
B of Health 2. Building Department 3. City/Town Clerk 4. Electricalinspector 5. Plumbing Inspector
6
Contact Person: '
Phone #:
A.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Constructiio Supervisor: Not Applicable ( ❑
Name of License Holder : ��� h ilv �_—� `O 9 c\
License Number
Address Expiration Date
Signa ` - Telephone
;". x- F°i'.., a'� an '"f t,, d �"'
5..Rp® inter tiit�ame: #im#?ral iffi r _ iiib aatt � � _ilil y3. >�a � 3 ... ..... Not Applicable ❑
1 , �-
Comp nv Na e Registration Number
Address Expiration Date
Telephoned 6
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 ❑
11. - Home owner emp io
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)
rip( New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition El New Signs [D] Decks [E] Siding [D] Other [D]
Brief De riptipn of ose • . L _`� � ^
Work: ' . b VI\ t• 1` V�UN „ p J SR. S Y -- 4< Akilvl •\\ , 4\ L. \'!` V
Q (�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
4.10164t ° ioi se anld;i aritcl t tits eat stir.iii s r a cQilrl."aete i�li; itOititrjg:
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
1, L : 01\ \<—e., � .k. , as Owner of the subject
property
e
hereby autho 'ze • 1 1 • • —
to act .n m Ahalf, in al m - - fs relative to work authorized by this building permit application.
Sign • ure ofr ner — W Date _
I ► .■ • ' • , as Owner /Authorized
Agent her -by declare that the sta ements 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.
af' " )
_
Print Nan
Signature of Own Agent Date -
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Informatioa._
Existing Proposed Required by Ztning ,°'~ ,
This column to be filled in by
Building Department ,,
Lot Size , _
a
Frontage '
Setbacks Front i
Side L , - R N ---1 _ L:t R. :_ _ , ,_.
! € 1. _ j
Rear 5 I
Building Height ! ?`
Bldg. Square Footage _ % I 1
I
Open Space Footage . %
(Lot area minus bldg & paved I 1 1 1 ...'
parking)
# of Parking Spaces
Fill:
(volume & Location)
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 Q
—~
IF YES: enter Book . 1 Page ! and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location: ,
D. Are there any proposed changes to or additions of signs intended for the property ? YES a 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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
x; a a X 4- y ` �? r,. „�
"® 1 0F ,��
ity of Northampton
B ilding Department - e � ; I
r E1VED 12 Main Street a 4. a` w�
Room 100 . E, 4 .
%O% ort - mpton, MA 01060 _ �
MVP hone 41 t -5. -1240 Fax 413 - 587 -1272 Pir
f
Illil i.S.:r • NSTRU 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
� ', \ ),"�'^ S 4� Y 5 Zone Overlay District
`3
EIm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Recor
Int • - ' Yk .: 4 \ 3 (- 0 i cic---e- 3 () -e. . C . 4 . '
Name (•rint) _ Current Mailing Address:
A. 6 Telephone
Signs 411. —
2.2 Authorized A•ent•
1. vs \ " 1111 . l ..._ R 0 (--\) 0 1. 0 - 1 \ 1 0 ('‘'IVV)?+(li,— -
Na a (Print) Current Mailing Address:
,-- a.,- �l 0 -
Signat re Te one _
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)
kit V d o 0 Che ck Number p� b ;#
This Section For Offic Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings; Date
13 DICKINSON ST BP- 2012 -0559
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A - 098 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 -0559
Project # JS- 2012 - 000936
Est. Cost: $6000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 065699
Lot Size(sq. ft.): 4748.04 Owner: KENNEDY LINDA A
Zoning: URA(100)/ Applicant: BOB THIBODO ROOFING & SIDING
AT: 13 DICKINSON ST
Applicant Address: Phone: Insurance:
P 0 BOX 201 (413) 527 -7663 0 WC
NORTHAMPTONMA01061 ISSUED ON :12/8/2011 0:00:00
TO PERFORM THE FOLLOWING WORK :STRIP & SHINGLE MAIN HOUSE 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 12/8/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner