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25A-149
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, 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 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 to me. Date Address of work location .. -,. . The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigation 600 Washington Street %SEW= e, • '=IS:t=r; u Boston, MA 02111 . . . .. www.mass.gov/dia . -Workers' Compensation Insurance Affidavit Builders/Contraciors/Electridarts/Plumbers Applicant Information • Please Print Leeiblv A . Name (Businesi/Organization/Individnap: . . . • - A.C1;ire;s7 C- . , v- 'VW City/State/Zip: Phone.#: -Y-- co Arejyou an employer? Checli the appropriatebox: • . •Type of project (required):. i • 1.l I am a employer with I .. 4... 0 I am a general contractor and I 6. 0 Nexv coistiuCtion. have hired the sub-contractors employees (full and/or part-time). listed on the attached sheet: 7- O. Remodeling • . 2_0 I am a sole proprietor or parnaer- • ship and have no employees These sub-Contractors have. -8. 0 Deinc aion • . • . enAiloyerAandhave wOrkers' : . - - - . -. • working for me in any capacity. • , - 9: 1 01304ifik . " - clilitki [1•To workers' CO; insurance - comP- - . - - . - 100 . Electrical repairs or adclitions required.] , . 5. 0 We ait a corporation and its ' 3. 0 I am a homeowner doing ill work officers haVeixeraised :their . 11.0 repairs or additions myself [No workers' cornp. • right �f exemption per MGL 12.10Vizoof repairs " • • insurance required.] f • • ,C. 152, §1(4), and we have no • - . ' ex9ployees. [No wor - ' 13.0 Other , - -• ' . *Any applicant that checks.box #t must also fill out the section below showing theirvmdters' convensation policy infotmatien. tHomeownere who submit this affidavit incfiCatin,' g they are doing ail work and then hire outside contactors must submiia new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub:-contractors and state whetherornottboseattities have , . • employees. 'lithe sah-contraitorshaVe employeee, they milstpravidetbeir workers comp policy number. lam an employer that is providing workers' compensation insurance for my employees Below is the policyarul job site information. • . . .. Insurance Company Name .\..._\\ ,,,..\.., : 1 r\-t • •• c. Policy # or Self-ms. Lic. #: S -( i\ 4.5 0 N ILI4d 1 Expiration Date (3 7 4.:1 V . ' Job Site Address: S k,..pri b (ND viN4k kj-k. NAiv &zip' m 0 rb • Attach a copy of the workers' compensation policy declaration page (showing the policy number andexpiration date). Failure to secure Coverage as reqiiitiliiiicleir Seetroii'25A 152 can lead to the iiiiPoon 'of Ciiiiiinij Penalties of a fine up to $1,500.00 and/or one-yearimprisonmen4 as well as civil Penalties in the form. of a STOP WORK ORDER and a fine of up to $250 00 a day against dieviolatOr. Be advised that a copy of this statement may be foi - ffiVeitiii - tiOlis - Ofthi - DIAfOiiiiiiir'inCeCOViiiieiiiit‘calroii. --- . • : . Idd herebyCertiol under Me pains , • en • • ofperjury that the informatiOnprovidericifro4litmeirndiorrec. • \, . . • . Phone #: -?-"---\ ?-- 1(,_; C3 . . _ • . - Official use only. Do not write tn this area, to be completed by cily Or togniOfficlof • . . . - City or Town: • Permit/License # • . Issuing Authority (circle one): :1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electricalpispector 5. Plumbing Inspector 6. Other . . • Contact Person: Phone #: ' - SECTION 8 -- CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder 1 )b d kA) C- Q..,9 LiceiKe Number R as ( - ) Y - \ ;\ OANO" 0 " -- • G.) 1\4_ ir3 Address Expiration Date . I Sign - ture Telephone 9,::Rettistered, illii lnlproiue et`►t` aiitli6iieg E,_. : :M , i.. a aaas Not Applicable ❑ Company Name Registration Number Address Expiratton Date Telephone 5� riCpG-) 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 ❑ 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 ❑ Or Doors C Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [O] Other [II] Brief - D ription of Proposed \ '� Work: w\r,.Ck Q' "\ - . C T� 6 r� 0 Z' � k �( 1 b l L,0C C` Ct" Alteration of existing bedroom Yes No Adding new bedroom Yes No h th Attached Narrative Renovating unfinished basement Yes No 1 Plans Attached Roll - Sheet 4,4 [feteWhotisear miff a[i dttiordwexisfri cuifoitsin ti6i piefe tie : 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 ti , as Owner of the subject � r; C\ \ J AS V� ect ; property hereby authorize • s \ S to act on my behalf, in al matters relative to work authorized by this building permit application. X al Date Signature of Owner I, 111 S \ _ , as Owner /Authorized Age here!) declare tha 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. Print Signature of Owner /Agent Date 4 , Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by ?Zon d _ , This column tgbe file in by ; Building Department a Lot Siz ___ Frontage = _ _J ? -- _ ., Setbacks Front 1 Side L:1--.! R :1 L:......,_._._.i R:`. _1 i �... -- i Rear Building Height °°" j - �'""`' i l Bldg. Square Footage L= 1 % Li= = 1 1 Open Space Footage % (Lot area minus bldg &paved ; _ ? ' # - -- -- parking) # of Parking Spaces I _. 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 0 IF YES: enter Book ` f 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 I IF YES, describe size, type and location: s D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0 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 Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. - ED 7S1‘ City of Northampton St ,A.2414:44-0W w ' ' ` �E� Building Department © . 4 3 fix 212 Main Street 5 -t' sect to be co w +�._; '�2 letett � 0.A l �. �, � 3 .� °V BUILDING ` - Room 100 ° rioaT►+ Northampton, MA 01060 - 1' ,4 ., 1.1 Property Address: phone 413 - 587 -1240 Fax 413 - 587 -1272 - - - ;at r te' 2 .e APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAM DWELL SECTION 1- SITE INFORMATION This i on mpd by offi Lo U ni S �� d ?:.'-,A-. e \ 2one OverfayDrstrict tz- Etrri St District CB Dist SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: te r, \ � v n� 5 0 CA \)ir-e (v- Name (Print) Current Mailing Address: \ X L � / or c>l,— ft, Telephone Signature 2.2 Authorized Agent: t C \ v N� ° o f;,_.1() O-� Name (Print) Current Mailing Address 1 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 Cost Construc Total from (6) of 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection X 6. Total = (1 + 2 + 3 + 4 + 5) C.1 O Check Number / �K This Section For Officia Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 52 WOODBINE AVE BP- 2012 -0584 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25A - 149 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 -0584 Project # JS- 2012- 000995 Est. Cost: $7000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BOB THIBODO ROOFING & SIDING 065699 Lot Size(sq. ft.): 18556.56 Owner: DUNN JAMES PATRICK & PATRICIA Zoning: URB(100)/ Applicant: BOB THIBODO ROOFING & SIDING AT: 52 WOODBINE AVE Applicant Address: Phone: Insurance: P O BOX 201 (413) 527 -7663 () WC NORTHAMPTONMA01061 ISSUED ON:12/19/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: STRIP & SHINGLE SECTION OF 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 12/19/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner