24D-232 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 backlit!).
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 occunancv
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 to me.
Date .;e
Address of work A
location
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so
,
•
• '
The Commonwealth of 'Massachusetts
Department of Industrial Accidents . ,.
A =■''': fi,
Office of Investigationg . .
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1., 7 4111:1=-. Iii 600 Washington Street
,..;-=.241=• i
Boston, MA 02111
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www.mass.gov/&a ,
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Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers - -
...
Applicant Information _ _____ Print Legibly
r V
Name (Businesi/Organiiation/Indivirinni): S -- IR 1 n 0
' - Xd.Clie;;; 5 -)"
7% 0
City/State/Zip: & b -\ :.) ----, ,, n Phoneg: --- ) a - 1 , c, _
sA-\
,,,
Are you an employer? Check the appropriate ' -Type of project (required): ,
• 1. E s - i I am a e m p l o y e r w i t h ( 4.. El I am a general contractor and I
&DNewco]istruction
have hired the sub-contractors
employees (hill ancVor part-time).*
listed on theAtmched sheet 7- 0 Remodeling
2. n 1 am a sole proprietor or partner-
ship and have n.c..loyees These sub-cOntractors have s 0 D •
working forme m my capacity. en:AlloyerAandhave workers : ., - --... -; -
9: faattildmii&liiifin
Dskr workers' comp-. insurance
required.] .- - . 5. 0 We are a corporation and its 10 -0 14 ctrical repairs or adcrtions
3.0 I am a homeowner doing all work officers haVe4z..ercised :their . 11.0 Pubing repairs or additions
myself [No workers' comp. • right of exemption per MGL
12. Ell Roof repairs
insurance required.] t • • . p. 152, § 1(4), and we have no • ,
13.0 Other
employees: [No workers'
1 - - • .. . • . comp. insurance reqUired.). . • - ' '
Any applicant-that checks box #I also fill out the section helots/showing theirimdcers' compensation policy information
. 1. Homeowneri Who submit dtii affulaVitincficatin' g they are doing all work and theii hire outside contraCtorS must submit anew affidavit indica#ng such.
:contractors th check this box nmstatiached an additional sheet showiiig the name of the subcontractors and *state vibetherornotthose-entities have
employees. If the snb-contraciorshaie employeeS, they must providetheir wOriceis' comp. policy number. . ... • •
- i gm an employer that is providing workers' compensation insurance for my einplayees. Below is the policyandjob site
information.
.
Insurance Convany Name:7 • . \ ••
Policy # or Self-ins. Lic. #: (-3 (1 6 l..) ( &)a,S 0 No-iLioll txpitition Date: - 3 -a-i- .1a.. -
sco C
Job Site Address: (:), \ ( c - t . - t-C..‘; . S '' City/Stafx/ZiP47421".1■k
Attach a copy of the workers' compensation policy declaration page (showing the policy nunibek andeapiratiort date).
Failure to secure coverage as reqiiiiid iiiittek.Seetroil'25AIVICIGL re. 152 can lead to the iii-JiiOilitOii)13:13in;iliinallies of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the fonn of a STOP WOXIC-OBDER and a fine
of up to $250 00 a day against the violator. Be advised That a copy Of this statement maybe forWaided totheci , . .
Eireitieiriciis Cif DrAlliile'6'6 : ---- 7 . 17"777.77,7, ....:
do herehycerttb under t pains penalties ofiirjuryiltat the iiziornstitionprovkfidTabovairsin;jii4orret.'
titre:
) i3 .' : : -: D : - - L ''
#: s-4 , , ); ( c ., 3
izti use only Do not write izz this arerz, to be completed by city Or toWn'afficiaL
Town: . .
"- Pernut/License #
uthority (circle one):
'Health 2. Building Department 3. City/Town Clerk 4. ElectricalInSpector 5. Plumbing Inspector
. .
1: Phone #:
I
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 6 S
License Number
\S S S\\\4c \ L `ate ya,
Address / Expiration Date
C ^
Signature Telephone
9 .:Reciisttred.FlamO.lmpio4etnei C+aiittietoiii . • , F ;H d _ .,._ . Not Applicable ❑
Company Name Registr Number
E " V\ (AR S ck--
Address Expirati Date
Telephone SP 1 b-'
—
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affid vit 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 Dwellinss 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 buildin2 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
1
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing I
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [I ] Decks [E Siding [0] Other [0]
Brief t0 cription of 0 A
Work: ,. ►� . i .. III alf■ IP 'V a 1 ' - ® > ` J p
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a if istimetiguse/atinvradditignlo existing fioi s na complete thefoHiawiiiq:
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, C i\\ \r" \U r 1\ L , as Owner of the subject
property S - 3
hereby authorize ' 4c O
to act on my behalf, in all matters relative to work authorized by this building permit application.
Cm5 INV Ylii.JfilelAg 6 A.° 1
Signature of Owner Date
I, C) 1 a �\D 0 k0 , as Owner /Authorized
Agent herebye
A eclare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
9 Y
and belief.
Signed under or. pains and of perjury.
^ 1 � r b
Print Name
R -Ia)\` :- \VLIY0495-s cl ' C) 0
Signature of Owner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information .
r . .
Existing Proposed Required by Zoning ,
This column to be f led innby ,, j
Building Departm f no: 1 $$ 1,
Lot Size 1.- . ,.,..
Frontage ._- .._._.
Setbacks Front ?
Side L R. L: r i i R: i _W , _.
Rear = I
Building Height i r 1 F
Bldg. Square Footage ; 1 % 1-1 "" " ,
Open Space Footage , %
(Lot area minus bldg & paved .,.._ _ ,J ?
parking)
# of Parking Spaces 1 1
m w, .4 _ ,
Fill: .� .mm_
s ,t i
(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:; j
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page; I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained i Obtained ,Date Issued
C. Do any signs exist on the property? YES 0 NO i
IF YES, describe size, type and location: I
D. Are there any proposed changes to or additions of signs intended for the property ? YES (3 NO 0
IF YES, describe size, type and location: 1
w
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
RECEIVED City of Northampton t �� x41 ? i" , ' t: 41
Building Department �� °F f i .: :
212 Main Street ql
, i .,,, r,, , ,:: gill
2 ` Room 100
Northampton, MA 01060
r
e . 13- 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
Zone Overlay District
Elm St." District " CB. District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: � ,(
CatilPrint it,tr t9 iii(0 f r"os P 6.4-. Wo r - 1- hpup -f'a N
Name (Print) Current Mailing Address':
e tli -- .�nl Telephone
Signature
2.2 Authorized Agent:
1361 T► i 1964 h 3 Ea.St Mc /est., EEs 7 /-1'
Name (Print) Current Mailing Address:
1/3 - 667 - 7163
Signatur Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Offic 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) l'
5. Fire Protection ` /
6. Total = (1 + 2 + 3 + 4 + 5) ] \ r )--E) c) Check Number _
This Section For Official Use Only
Date
Building Permit Number: issued:
Signature:
Building Commissioner /Inspector of Buildings Date
216 PROSPECT ST BP- 2011 -1078
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 232 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- 2011 -1078
Project # JS- 2011- 001740
Est. Cost: $1200.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 065699
Lot Size(sq. ft.): 5880.60 Owner: MURPHY EDWARD J & CATHERINE M & MURPHY DIANE M ET AL
Zoning: URB(100)/ Applicant: BOB THIBODO ROOFING & SIDING
AT: 216 PROSPECT ST
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527 -7663 0 WC
NORTHAMPTONMA01061 ISSUED ON: 6/22/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: STRIP & SHINGLE 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 6/22/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner