22D-063 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 fandly
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 constraz;tign 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
. ' 7
. ,
The Commonwealth ofMassachusetts
=.7.......,---- Department of Industria I ACcidents
s t —......,,.=... ,,,
Office of InVestig,atiord . .
t Maillz--- 5 600 Washington Street
--1.1...... ...,#
Boston, MA 02111 . .
www.mass.gov/dia ,
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
,..
Applicant Information • Please Print Leeiblv
r
Name (Busineseorranisation/Indiviclual): r4) i r . :; 1 ) ... 4 &t,,
. • Addi-essW).01 ;
City/State/Zip: N 0,, ,„,,,,v \--b,,,,A Phone.#: 5 /i (", (03 -
,„,
Are you an employer? Check the appropriatebox: • .Type of project (required): '
• 1. cu; I am a employer with ) 4. 0 I am a general contractor and I
6. 0 New c - on
employees (fall and/or part-time).* have hired the sub-contractors
listed on the attached s heet 7. 0 Remodeling
• ship and have zio epployets
2.0 I am a sole proprietor or partner-
These sub-contractors have 8. 0 Deinolition •
wor f orme i any capac errii_ oyees____-andhave workers' : _ - --.....• .. -. . ,.. -
9 frirtiildriagi&litaai
[No workers' comp. insurance •
10.[=1 repairs or adclitions
required.] , . • 5. 0 We are a corporation ancl its
• 11. l
e mbg repairs officers haVeCtereiseclrhir um or additiOns
3. 0 I am a homeowner dOing ill work
myself [No worimrs' comp. - right of exemption 'per MGL • -
12. Roof repairs .
insurance required.] t • c. 152, § 1(4), and we have no •
employees. [No workers' l3-t-i Other
. -
, . .
comp. insurance rerlUireci-1 - . • • • : .
- .
Any applicant -that checks box #1: must also fill out the section belay/showing tbairworkers' compensation policy information.
t Homeowneri who submit this affida;ritincfidating they are doingafl work and theit hire outside contractors must submit a new affidavit indicatin: g such.
:Contractors that check this box must attached an atIfitional sheet showing the =MC of the sulcontractors and Stine witetherarnot entities have
errpioyees. ff the sub-contractorshaie employees, they must provide their wcakers' comp. poNcynumber. . • .., ! • .
, . •
I am an employer that isproviding; workers' compensation insurance for my employees. Below is tit e policyandjob site
information. .
Insurance Company Name: . --- 1 ---- tiZ . A c, ,,,,k; C • . -.. , - •
POlicy # or Self-ins. Lic. #: C U r \ l ) 4 4-5 i\I I Li L( 01 ( ExPration Dare: - 4'
. \ . .
Job Site Address: 3 Q) ()\.( -''""..• ' Crty/Sta&Zaix - •
Attach a copy of the workers' compensation poll declaration page the policy number and *.apira.non date).
Failure to secure coverage a.S required Mad SeetrOir 25A ofMGL c. 152 can lead iiiiPoiitibii ifif penalties of a
fine up to $ 1,500.00 and/or one-year imprisonme4 as well as civil Penalties in the form of; STOP WORIC-ORDER. and a fine
of up to $250.00 a day against the violator. Be advised that a copy Of this statement may be fOrWaraedidtlie.04e
FeitiiitiOiis tiii DIA. for insurance ctiveia6V • ' 7... - 777 ,....-. -,:---,-.:„........., .7 .1 .
I era herebycertifil under the pains-and pergartl iiolperjury that the hiforinatiOnprovidezliaboveListrue_andiarihict _
10 t . 1,
Si.u..tii: V I I -.'s A ■___ A * AL;s1MVAI■ ' ' • . •
. ,
Phone 0: S * 1:' (7 1 (0 ( : --- • -• ' • • - - • • . .
. - Official use only. Do not write in this area, to be completed by city or towneiciaL
.. . , . .
. -
City or Town: "- Permit/License # . _
Issuing Authority (circle one):
. 1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalIn.spector 5. Plumbing Inspector
6. Other .
Contact Person: Phone #:
.. ,
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 1 �� C) kA, C G 9' C\
License Number
Addres Expiration Date
_, 1 _' lease. _ lease. S , J
Sig a u Telephone
lbs.;i2e:is • ®w: to ro4 emffnt€7 o afkidatitigi:iii Not Applicable ❑ S'A ComYNe Registr Number
Address Expiration Date
3 ?-43V31-5611 Telephone
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 buildjng permit.
Signed Affidavit Attached Yes [� No ❑
ni ' 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 Icheck all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [0]
Brief Des 'pti• , of - gpos•
Wo . ► W . \ V '* I ■ • e d' t _ 6Y'CAl Qati
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa e lf, Ne iirtto i iiiMi d ifiW ta4 ist ix ri c rrtf! 6litiiiiti lii oiic i ct:
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
I, (7 \ - ? - 1 1 e..c - en..--e CA—C\ -_V \\ , as Owner of the subject
property �
hereby authorize $ n ) ` iPt. ‘ b 6 0
to act on my behalf, in all matters
4 matteersellative to work authorized by this building permit application.
A9 1C j'" *4 -mac!' itti ' t
S ignature of Owner / Date
I • ■ (j " , as Owner /Authorized
Agent ereby 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 painsnalties of perjury.
P Alli. 0
Print
Signature of Owner /Agent Date
I
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due T'o Incomplete Information
Existing Proposed Required b tilt
This column to be filled in by
Building Department
Lot Size _ _ w
Frontage _ _.. . _..
Setbacks Front --- --- - 1 ( f
Side L R:. 1 L:i 1 R: 1 _—
r i = 7 I
Rear I I
Building Height t 1 = _.
Bldg. Square Footage % F i j i i
Open Space Footage l I %
(Lot area minus bldg & paved 1 _„ (
, , E=1 ! i f
parking)
# of Parking Spaces € _
Fill: t,
(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:;
i
•
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book ? P age 1 and /or Document ft
B. Does the site contain a brook, body of water or wetlands? NO 0 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: L
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 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.
E of orthampton
Bui sin Department �N
5 zo%% 2 2 ain Street = s�
Roy m 100 - r E®
pEPi.OF w e cs. pt n, MA 01060 1 _ v
IL ov . G
Noa = 0 Fax 413- 587 -1272
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
- ;b V1 C - & SZA Zone Overlay
Ern St fDlstrlct.. CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: r ailing
Jt \ lam �ress
l
N me
(Print) Cun• A d � ��
(Pri ,, a ,..
RtiC /, - �i 4 iJ PLC :.. Telephone
Signature
2.2 Authorized Agent:
e - L d p *\t� �
Name (Pnn Current Mailing Address:
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) ( Q 4 Check Number /
1 1 This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/inspector of Buildings Date
63 FLORENCE RD BP-2012-0004
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 22D - 063 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 BUILDING PERMIT
Permit # BP- 2012 -0004
Project # JS- 2012 - 000010
Est. Cost: $1000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 065699
Lot Size(sq. ft.): 10236.60 Owner: MANDEVILLE BERNARD J & CELESTE
Zoning: URA(100) //WSP Applicant: BOB THIBODO ROOFING & SIDING
AT: 63 FLORENCE RD
Applicant Address: Phone: Insurance:
P 0 BOX 201 (413) 527 -7663 () WC
NORTHAMPTONMA01061 ISSUED ON: 7/5/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE PORCH 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 7/5/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner