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38B-163 4 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, act as their owrr contra ction 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 occuoancv 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 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 opfassachusetts Department of Industrird Accidents Office of Inilestigation.s • . =r4111:.---. .• • 600 Washington Street Boston, MA 02111 . . „ - -,:-..- - 7, , , www.mass.gov/dia . . • -Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers plicant Information Please Print Legiblir Name (BusineseOrraniiation/Indivklual): • - . Address: S r ...„ E City/State/Zip: . 3N,, -,-- A -- \,,.„,e 4-4,-. Phone.#: 5 -- 1 Co c; 3 - , Are pu an employer? Check the appro&iatehox: • . -Type of project (required) 7 • • 1.a! I am a employer with 1 • 4•. 0 I am a general contractor and I 6. 0 NC07 CO ' 'on • have hired the sub-contractors employees (full and/or part-time).* listed on the attached sheet 7. 0 Remodeling . . 2. 0 I am a sole proprietor or partner- These sub-contractors have. -8. El Deinoliiion • . • ship andhave no employees working forme m any capacity. e PT- 43 -Y•P-P 4 : nd -- - 11a ve wmkers 9 12-B- -----. --i----,,,,,,H [No• workers' comp-. insurance • - comp ii?tarince-t - . . -____ r _ i r - . 5 . 0 We are a corporation and its 10.0E1. •..".,- repairs or addition - • 3. 11 I am a homeowner doing all work Officers Illire.tweraisect their • 11.0 .,.. •ing repairs or add]tions . myself [No workers' corrip. - right Of exemption per MGL 12. 21 Roof repairs . • insurance required.] t • • : p'. 152, § 1(4), and we have no • . employees: [No workers' 13.0 Other r • . . . • ' ' • . ” COI0p. insurance recinired.j. - . • - . . . *Any applicant -that checks box #1 must also fill out the section below showing their*odcers compensation policy ioformatiOn: t Homeowneri who submit this affidavit incfiCating they are doing all work and then hire outside contractors must submila new affidavit indicating such. IcontrActors that check this box must attached an additional sheet showing the name of the sub:-contractors and atate whetherornotthose.entitita have . • employees. 'If the sub-contractorshaic erzq3loyeea, they mustprovide their work:ths' comp policy number. lam an employer that isproviding workers' compensation insurance for my employees. Below is the policyand job site information. : . Insurance Company Nain - \--Nr:NYA"ct.) •i - : . .• ' . . - Policy # of Self-ini. Lic. : C6 5 c > Li 5 o 1,5 0 N (Li Li 011 Expirat Date ion :- 1 Job Site Address ":. 3 • - - • # • ,... ess: 0 0 - r• _ s , • City/State/Zip:' \NNI\,c_y a - , t - Attach a copy of the workers' compensation policy declaration. page the policy rittinlier and•expira on date). .,„.. Failure to secure coverage as reqUirelinictei Se'ctiiih 152 can iead the imposition Ofaiinriiiij penalties of a fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP W01?.IC-ORDER. and a fine of up ta S250.00 a day against the violatOr. Be adyiSedfthat a copy Of this statement may be forwarded to theOili'ce - Efeiliiitioiis - ofthi DIA. for insurance' erviernie Vilification •. •. •. _•_. • .• . ....., ::-.--.„.;_• .,,....-.,..-: s .,..,...: „.„.:,.. .1 ,, ,... . „ ,.., • _ Idd herebyezirtib.under the pains.and penalties olperjury thairthe informati.onprovideit_abOi4Latime.azath rifEct' . - • . lb V .1 ,- ' ' ' - 15- - ' I- V). - , Siariamre: • • ate: - . • . Phone ii: 4 .- - 1 co fcp3 . . - • . ' ! --- -- ' . ' •• _ - • • . • - ''''' - - ---- - . . . . - Official use orzly. Do not write in this area, to be completed by crty or town officzaL . . . - City or Town: - '• Permit/License # ' _. Issuing Authority (circle one): • :1. Beard of Health 2. Building Department 3. City/Town Clerk 4. Electricaljnspector 5. Plumbing Inspector 6. Other . • Contact Person: Phone 11: .,,,, SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 • Name of License Holder : ('I \ O�� (S JJJ License Number Address Expiration Date . `` ` , - v... ! i 1� . 1 Co � Signature Telephone 3.';Re tstere lltiiru mdroemeirrt lit Kt4 r '.: it `..F.' `,,. Not Applicable ❑ \ 0 \ S I ` Y)-- Company Name Registration Number Address Expiration Date /10::0•Zok:ftraer Telephone – 1(3 cl SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affid it must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buil ing permit. Signed Affidavit Attached Yes No ❑ 11. lk:'Mthue.Ownerlitemption 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 t SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks LD Siding [0] Other [0] Brief D.- ription of Proposed • A • A _� 7 Q "1 Work: �� . . a r►s \■ v v 1\ q Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a if ieir tioiiii fidi iad ti t iitt ' a ; t n e e. tke oltr *tha: 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 I, i 6 k` r)Y1 , as Owner of the subject property hereby authori c^j to act on my b If, in matters relative to work authorized by this building permit application. Signat of Owner Date 1, 1 1111 0 111 1 ilk _ , as Owner /Authorized Agent hereby declare that the statements an• in ormation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and enalties of perjury. f li --- 0 Pnnt IWdme L i -- . 4 A , Signature of O g f1/4 " a " )41°--- Date i. a Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning ' J This column to be filled in by Building Department Lot Size -- -- ---- --. - . Frontage ,-.. •--- - ._ . _..1 Setbacks Front , 1 Side L 1 . _p R J L:i R:, _. i , r i i Rear .. - J 1 Building Height 11 a Bldg. Square Footage i 1 % 1 1, ! Open Space Footage i % 1 (Lot area minus bldg & paved L..... „ , _,,,, L � ' parking) # of Parking Spaces „. Fill: (volume & Location) . 1 .1_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:;. IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Books i Page; and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW (2) 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 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 0 __ IF YES, describe size, type and location: 9 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 4 .)- i p F - ` C of Northampton p z 0 �� Bui 'ling Department u D x .1 a k .� � a� 21 Main Street � A.� \\. 5 �-C' ZO R oom 100 : �e GIN Pcs ����y.' �M orthampton, MA 01060 A = A o ,c. v` one 413- 587 -1240 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 tone Overlay" District \ Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: C).0 -c Sk . 1\ft-1-..r. - N , ..., o r■ Name ( Current Mailing Address: %):\fir'" Telephone ? ¢ U S v ` scO �' Signature 2.2 Authorized Agent: _ 'C- I. i ■ � ' 0 y V 0 X 1). d t,Y� t� N. a (Print) Current Mailing Address: Signatui� 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) 5 © 0 0 Check Number -Q�� r I This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings, Date 20 FORT ST BP- 2012 -0921 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B - 163 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 -0921 Project # JS- 2012- 001606 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.): 9147.60 Owner: AHEARN MICHAEL J & PATRICIA M & PATRICK & MICHAEL & DANIEL Zoning: URB(100)/ Applicant: BOB THIBODO ROOFING & SIDING AT: 20 FORT ST Applicant Address: Phone: Insurance: P O BOX 201 (413) 527 -7663 0 WC NORTHAMPTONMA01061 ISSUED ON:4/24/2012 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: 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 4/24/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner