32A-027 (2) 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 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 occunancv
until the work can be inspected.
If the homeowner hires other trades to perfonn work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
ennits 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
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 rne.
Date
Address of work
location
. .. 1 1.
41 1
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The Commonwealth opfassachusetts
Department of Industrial ACcidents . ,.
10
Office of Investigation.
c =„T.1111.:----. •'; 600 Washington Street
e. •=lif,=— Z Boston, MA 02111
•
www.mass.gov/dia .
• '7,
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
,
Applicant Information Please Print Legibly -:
. : .
Name pusineseorgathiationanctivid.D: Bo /2 76 a
: ..
- • Address: /39 6-1 0 I, e i ,- • .
i ado/ , ,
City/State/Zip: Ntri 11/7 Phone.#: qt 3 -5/' - "•74 1 •3 -
Are d ou an employer? Check the appropriate'box: • -Type of project (required): /
1. I am a employer with / .
4• 0 I am a general contractor and I
6. 0 New co - . 'on
have hired the sub-contractors
employees (fall and/or part-time).*
listed 011 theattached sheet. 7. D e R,modelfrisr
2.0 I aril a Sole proprietor or partner-
ship andhave no ...loyees These sub-contractors have .8. 0 Demolition
working forme in any ccpacity. elrAgO-Yee4.-14-0-437e workers' 9:- -0-Butai*
[No workers' comp. insurance - enn - -
. ..........._____;_._ . -
officers 10.0 Electrical repairs or additions
3 0 I am a homeowner do
requ „ . , 5. 0 We are a corp tion and its
. ing all work cers haVeUeraised their .
. 1 11.0 Plumbing repairs or additions
myself [No workers' comp. - right Of exemption per MGL
12.gRoof repairs
insurance required.] t ' e'. 152, §1(4), and we have no • .
employees. [No workers' 13.0 Other r
: . •
' . comp. insurance recraired.j. . •
*Any applicant -that checks box #1:must also fill out the section Mots/showing their svorkers convensation policy informal:inn.
t Homeowneri who submit this affidait.incfsdating they are doing all wait and then hire outside contraCtors must submit anew affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the subkontractors and stale wheth er or notthose entities have
employees. If the sub-contracitorahaVe eimployeea, they must provide their works ' comp poHcy number.
/am an employer that &providing workers' compensat insurance for my employees. Below is the policyand job site
infonnation. •
Insurance Company Name: - Th.1 , - ijr.t . .; i tt . P7.2...-" . . • -
Policy # or Self ‘1 qq I I
-ms Lac #
. . :
. tap Date: - •
A / A i .„:
Job Site Address : I- a- _Lac/ f' Li -SA A/OrtillivirieN /S MIZip
ity ta.
Attach a copy of the worker?" compensation policy declaration page"(showing the policy ininalier and date).
Failure to secure Criverige . as required iniiteir.Seetroif 2 6fIVIGL 152 can lead to the imposition ofainaiiiej Penalties of a
fine up to S1,500.00 and/or one imprisonment, as well as civil penalties in the form of i STOP wop.KARDER 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.0•M'c
'Hireitietitions oftliFDIA Etiiiiiditrcii - : 7 -- - - _ - . - 777:=7.= .....:...7
_ I it7r4 uri16;1. t.4e pains,and enalties of_perjurythal the infornsatiOnprovidir(iibin;andion;c7 _
Signatir • • • DaM: /7- / -7 /
---.-
Phone ti: 0 -- 1 74 ° & ... - .. ' : - : ' . . . - _ •
. - Official use only. Do not write in this. drat, to be ciiiiipleted by city - Oi; thWiOfficial.
. .
City or Town:
Issuing Authority (circle one): "- Permit/I.icense # '
.1 :0th Boar
Contact p do a 2. Building Department 3. City/Town Clerk Phone E ifi tr ilcalinspect; 5. Plumbing I
6
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
Not Applicable ❑
Name of License Holder : /3L / 7 � /.(� O i? D �✓ Y
License Number
�U . 01C d , 111 a4 /14 6
Address Expiration Date
i /3 7 - 7W3
Signature Telephone
9: Registered, . Home Iiiiprovim t'C( toe . -_, �° ._ ,A._, .F. �.,.: , .... .: Not Applicabl ❑
Arld 7/ bei Y =..Jcr�"�K- R � on Number
an Name r
g
d 4 doi 'ari 6 afar / �- i - / ,--
Address � Expiration Date
Telephone 7
7/3 - Z
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 ' g permit.
Signed Affidavit Attached Yes No ❑
11: �. H�m� U�vner �emp�ian
The current exemption for "homeowners" was extended to include Owner- occupied Dwellines 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 1083.5.1.
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 D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other [0]
Brief Qescription of Propose ;
Work:' s. ■ ► � % i 461 t ' L. _ ` � , ,. A 00 1
_ 1
Alteration of existing bedroom Yes _ No Adding new bedroom Yes No ‘ \c, �
Attached Narrative Renovating unfinished basement Yes �No b \'N'N
Plans Attached Roll - Sheet
s Whitt nr, tidtiei4i r' iddtitift , eiktiltiii hauihiiUiiiatif h k otidWir a:
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, Alfa) /(I. i 2L , as Owner of the subject
property � -,� -� ( -
hereby authorize - 864 16 1( bah
to act on my behalf in all matters relative to work authorized by this building permit application.
�l�i � '7 - 1
Signature of Owner Date
I, O 71; / .41, , as Owner /Authorized
Agent hereby 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.
e /, 1 /bC'a0
Print Name
Signatu 7 rOwner /Age Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning ,..
This column to be filled in by
Building Department
a
Lot Size ! L . . J L
Frontage - - ,
i
Setbacks Front
Side L R:' L:' .._ R:' __J '_
Rear , ' = ,
Building Height i r 1
Bldg. Square Footage t ""'"'t % 1
1 x. •
Open Space Footage
'1 i
(Lot area minus bldg & paved _ a..
parking)
# of Parking Spaces .., __
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 ! ) Pagei -- and /or Document #
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 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. WiII 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.
.ra°� , f m t aei ,..,. „ ltEl , ��
ED ity of Northampton
®Pet}xr€ �
,: uilding Department C rr b l#r B - _ ? �� lt� S
�
212 Main Street Se _ k5,il 3� , 4�
- 5 20 11 Room 100 i . @ . ,
'� - o hampton, MA 01060 = .�
• a - :• 3- - :7-1240 Fax 413- 587 -1272 P
1WING NSP : :.,".r : . , , ,fa
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
x _M ap Lot Unit
se Cry ,S7
Zone Overlay District
Elm St District CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: A V e tl 11
/9bcilrei.4 i itkij4-Se-k it Name (Print) Current Mailing A, � ` s
" Z -
1„4 J4 ��4 )4-' Telephone _ (,,,t4,4'1
d �v 3
Signature
2.2 Authorized Agent:
736bTh4d .J&sf Mapk,s /. 404(A- /
Na a (Print ,./� ; Current Mailing Address:
Signa re 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 0 Check Number 0 75 7 a A
This Section For Official Use Only
Date
Building Permit Number; Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
30 CHERRY ST BP- 2012 -0003
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 027 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-2012-0003
Project # JS- 2012- 000009
Est. Cost: $1500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 065699
Lot Size(sq. ft.): 7448.76 Owner: KUBASEK ANDREW E & MARGARET W
Zoning: URC(100)/ Applicant: BOB THIBODO ROOFING & SIDING
AT: 30 CHERRY ST
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 LOWER FLAT RUBBER 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