38B-126 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
jermits 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
Date
Address of work
location
` P
. The Commonwealth of Massachusetts
Department of Industrial Accidents .
AA,— . Office of Investigations • t.
9 ° ; �_ 600 Washington Street
.. Boston, MA 02111
�� www.massgov /dia
• -Workers' Compensation Insurance Affidavit Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individnsp: O\ F'� \ � )/ it )
Address: E .
City /State/Zip: �; o-4 ;. c.4 'i ba.`�Phone. #: �c�� 6 (03
y .
Are u an employer? Check the appropriate box: Type of project (required): i
• 1. I am a employer with I 4. fl I am a general contractor and I 6. 0 New construction
employees (full and/or part-time).* have hired the sub - contractors
2..Q I am a sole proprietor or partner- listed on the attached sheet. 7- ❑ Remodeling
ship and have. no, eu ployees These sub - contractors have. 8. 0 Denoliion
working for me is any capacity_ employees and have workers' •
9: Burl addition
[No workers' comp. insurance - comp. inset „c p ; _ .. __. .:.
required] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
officers have their mepairs or additions •
m g
3. 0 I am a homeowner doing all work ,,.: 11. unib• r
self [No workers' co right of exemption per MGL
Y comp. 12: Roof repairs •
insurance required] t • c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp, msin-ance required-3 • •
'Any applicant that checks box #1 must also fin out the section below showing their workers' compensation policy information:
t Homeowners who submit this affida indicating they are doing an work and then hire outside contractors must submit a new affidavit indicating such.
1 -Contractors that check this box must attached an additional sheet showing the name of the sub=contractors and state whether or not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
1 am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: I I 1 CA Af COY / •
Policy # orSelf ins. Lic. #: `Gl C v C) (ir), Q N 19 ( ( 0 I ( Expiration Date: 3 -� -.
Job Site Address: L( 7 4p. 9 ` ' city/state/zip: N v, h -)
Attach a copy of the workers' compensation policy declaration page •(showing the policy number and expiration date).
Failure to secure coverage, as required'i rider Sectiiiii25A ofYIGL c 152 can lead to the naposition of'crimmal penalizes of a
fine up to $1500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK-ORDER and a fine
of up to S250.00 a day against the violator Be advised that a copy of this statement may be forwarded to the Office of
Investieations of the DIA for insu coverane' • i
I o d hereb _,certi under the pains d enaltie's o , '
- ._ �' .fy p p fperjurythat the information provufedabave_Lttrue asd cvrrer.t.__ -- - -
� s 5 1 '
S pate - .
Phone #: 51;1 . ` L (ca
ff y area, mp . by �y ...._..,._ _ .
Official use only. Do not write in this are to be co feted b or town offciaL
City or Town: Pernut/License # „_ „
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
p.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction S •ervisor: Not Applicable ❑
Name of License Holder : 111 • • 1 1. `� S (-) q
License Number
C d\), 3
Address Expiration Date
ajl
Sig ur Telephone
S.';Rectistef r ..Hdm t vemef airi ractor agaaZlir t , a .„ .: Not Applicable ❑
Com v Name Registration Number
F rt-
Address Expiration Date
E '' ;>41 --
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 burg permit.
Signed Affidavit Attached Yes No ❑
1 .r. om Owner Exemptio
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. .1 t a4 _, I \.1KIN 4 .
The undersigned "homeowner" certifies and assumes responsibilit / 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 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [l=] Other [0]
Brief .cription of Proposed (' 1 L y �
Work: _Tl�-proii-k (N 41-1 , _T�°llr.� \\*Cit.S-k - �' S "1 90 lf 311 1 `.�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa If ern of is : is c ltli# t n .f+� c t r c �i s n ; a irr ilete the fa 0V41ftq
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 WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
r
1 , \ )N 5YQ.keir , as Owner of the subject
property
hereby authorize
to act on my behalf, in all atters relative • work authorize. - is building permit application.
4119 r
Y ' 1
I _ " ate.• •.1 � _ . — — . 1
Signat - of Owner Date
I, 1 9 C , as Owner /Authorized
Agent heresy 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.
6 1J
Print Name
Signature of Owner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete 1 formation
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size 1 i
I. A
Frontage
Setbacks Front n i
Side L F R: L: R:. _
Rear I i
Building Height f 1 __; 3
i. 1
Bldg. Square Footage 17 [ 1 % [] 77 E
Open Space Footage
i
(Lot area minus bldg & paved i
parking)
# of Parking Spaces [ 1 __
Fill: 1 - -_ _ q t .o 0" (volume & Location) i; t?\.,4 /%
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' and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 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 0 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 O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
8.0t0 NOldWVM1Fi•N ;
U� 3 �svi nNia�ine do ia 3o City of Northampt
sNO "
Building Department i " _� ��
y ^I 212 Main Street ,f m • g �` ,, 4-0, , � 1 Q
I I n Z /� Room 100 "�
t
Northampton, MA 01060 4 = = , -, -!
(y j , ` j ` 4 . phone 413- 587 -1240 Fax 413- 587 -1272 - ,
a - ; axe 's e" 4�. F ,�.. a
ps ,r ,,,, >..... ; + ,.- Ys $ ,,, x.-. ._., ..
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
Map Lot Unit
34 v Y`'.' U S (1V-( Zone ' , Overlay District
Elm St. District CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
ck &be c QA 5l -1 _ (.d -{-- 34 1 u ti...`D s -AV
Name
. ;CZ t tjyte€,?4, (Print) Current Mailin re s: 1
Sitleggirk- Telephone
Si nature
2.2 Authorized Agent:
1 11, IN/ 1110 US v 6 II. ._ q °:. / ■ ) ( 1 a"- CZ k NUNC4
Nam- (Print) Current Mailing Address:
• t � SA 9(
Signatu 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) \ 0 I� 0 Check Number
This Section For Offic Use Only
Date
Building Permit Number: ed:
Signature: �� /!�
Building Commissioner /Inspector of Buildings Date
l X 3 4 COLUMBUS AVE BP- 2011 -0965
GIs #: , ' COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B -126 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUI PERMIT
Permit # BP- 2011 -0965
Project # JS-2011-001583
Est. Cost: $10800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 065699
Lot Size(so. ft.): 9539.64 Owner: SPECTOR LEE A & REBECCA S NEIMARK
Zoning; URB(100)/ Applicant: BOB THIBODO ROOFING & SIDING
AT: 34 COLUMBUS AVE
Applicant Address: Phone: Insurance:
P 0 BOX 201 (413) 527 -7663 () WC
NORTHAMPTONMA01061 ISSUED ON :5/24/2011 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: OJ( 7 f 2 V) C./t
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND RE . , S ONS / ,
Certificate of Occupanc - 1 4 " att(re: �'` ' `oa4ifv
Imo-
FeeType: Date Paid: Amount:
Building 5/24/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner