32-028 HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the light 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)t
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
hermits 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
. . - .
The Commonwealth of Massachusetts
Department of Industrial Accidents . ,., •
Allk.....■........ .... .E....m.■49
• Office of Ini,estigationS .
600 Washington Street
• --Ilif— •-?: Boston,MA 02111 .
-
. :
www.mass.crov/dia
•
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers -
Applicant Information Please Print Legibly
Name(BusinesS/Organizalion/Individualc- 1 ‘ b cf, sAJO ,
-.....,.
- Address: `33.■ C:4\S-)t Irv\CA
City/State/Zip: i• "\;\i‘ t'0,7-N Phone.#: 1 - ) (o 673
Are;on an employer?Check the apprbpriatelox: • Type of project(required): 11"
1.g I am a employer with I 4. 0 I am a general contractor and I
6. 0 New construction- . '
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-
sub-contractors have S. 0 Demolition •
ship-and ha.ve no employees
working for me in any capacity eamiloyee_a„andllaye workers' : ,- -. . -.- •
9: iildiffeaWidon
:-
10.0 Electrical repairs or additions
, .
5. 0 We are a corppr:alion and its
3.o lama homeowner doing all work officers haVe r.eraised their . 11.0 P ....•Mg.repairs or additiOns
right of exemption per MGL .
myself[No workers'comp. 12.IR • 'of repairs
insurance required.)t • - ,c.. 152,§1(4);and we have no • .
. employees.[No workers' 13.0 Other
, .
• . comp.insurance ref:it:lit-ed.).
*Any applicant That checks box/*must also fill out the section below showing dazirworkess compensation policy informal:him.
t Homeowneri who submit this affidavit iturMating they are doing all work and then hire outside contractors must submit anew Affidavit indicating such.
tContractors that rhi4-le this box must attached an additional sheet showing the name of the sub-contractors and state whether or nottbose-entities have
employees. lithe sub-contractors have employees,they must provide their workers'comp.poficynmnber.
, .
•1 am an employer that isproviding workers'compensation insurance for my eMplOyees. Below is the policYandjob site
information.
■ \,..- ,,
Insurance Company Name: 1 1\ '' 1 .C.-I',7\--%-c 0 v-r-''' Q : • ' . ' •
t
,.1 ., , ,. . „ ,
POlicy#or Self-ins.Lic.#:1:,--)SC Ur?:).:".:"A-.._) 0 N 1-1'1 P k‘ Expiration Date:-3' '4.--\ , \:--A •
.
Job Site Address: I ?K., ,f-. y-,k, d'-r• :. City/StifriZip:' ' ,
Attach a copy of the workers'compensation policy declaration page-(showing the policy number and eapiration te).
. . . . .
Failure to secure Coverage.as required birder Seetroir'2.5A-OfMGL.C.:15.26iii lead to the imposition Of Ciiiiiiril Penalties of a
fine up to$1,500.00 and/or one-year imprisonment;as well as civil penalties in the form of a STOP WOR.IC-ORDER,and a&_e
of up to 5250.00 a day against the yiolatar. Be advitecl that a copy of this statement may be forwarded to the:cotride:0f ;„.,,._
Efeatiratiaiis-Of th-e-DIA foiiiiiiiral-Ce coverage verification - ' .._ :' . -: _._ "„:,_.
_I do hWehyjaitifilunder the pains:and pew:hies ofperjray that the information provkied. sibavelrlieriP 11.240TrAid.' _
51g3;atiii,e: 171r'-gZ, I 4-7 t r t(11 . ' -: - —. rate
.
'
Phone ii: 5-' - ‘- \ 7-1 G (0'3 . . .: ' . . . - . . .
-Official use only. Do not write in this tiria,to be completed by city iii lowilafficiaL
. •
City or Town: - ". Permit/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#:
' -
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not(Applicable 0
Name of License Holder: � Thr V400 \, `c)
�,,,,,Q� Licen Number
`�A�' S�"� 0 C.,�,-,
Address Expiration Date
c'" `3
•
Signa ure` Telephone
9.`Re"aistprei Home.l(npfroudinent.Cr r�raefik`f 1V3ggigtIti&ZiagalgrafaTfkit Not Applicable ❑
Co pane tame Registration Number
`3 E s\ c 5�r �s \L \
Address' Expiration Date
,- �\ •e Telephone 3-X-1'-1 6 G-1
-
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 build' g permit.
Signed Affidavit Attached Yes No ❑
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(check all applicable)
New House ❑ Addition El Replacement Windows Alteration(s) ❑ Roofing
Or Doors El
Accessory Bldg. ❑ Demolition El New Signs [D] Decks [p Siding[D] Other[D]
Brief De cription of Prop sed j� .�
Work: '��(� � Z�C � �vv■ ��` 6 R \' 'C 1'1Z VzG V tv)-(ft--V
c {
Alteration of existing bedroom Yes No Adding new bedroom Yes No ' "°\`
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sad lid [e ho ise a r additl rr oexist q housin tnl F+l the llcwi �t:
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, .MC.)∎7 \>c i"/1 J ,as Owner of the subject
property i_ l
hereby authorize d t Y` v
to act on my behalf, in all atters relative to work authorized by this building permit application.
ig :ture of Owner Date
I, 111 \) • , ,as Owner/Authorized
Age"'hereby statements that the statents 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.
n � V�\ 1� nLla
Print Name
Signature of caner/ gent Date
i
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
Lot Size 1—___.. .. .. __
Frontage I 1 t r
Setbacks Front ; I_
Side L:3 1 R:z L: J R:
Rear
Building Height
Bldg.Square Footage I I % 1-1 = 1
Open Space Footage %
(Lot area minus bldg&paved � ,,, d L.
2 �
parking)
LL
#of Parking Spaces - -— ____
e.
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 Q 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 Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
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: if
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.
RECEIVED x A D .,. , zq k
ity of Northampton '
:uilding Department « . . e Pla
212 Main Street
1.---
APR 2 ., 2013 I �.g
_J Room 100
DEPT.OF BULLING!NSF CTiONS N•rthampton, MA 01060 i g -
NORTHAMPTON MA,,;.; _ , _587_1240 Fax 413-587-1272 � "
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map '" >Lot Unit
1 H eve r SA-- -Zone Overlay District
Elm St District CB.District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name //(Print)�� Current Mailing Address: 0 5.
1 ill(f✓ L '*v*0132"\--., Telephone
Signature 1
2.2 Authorized Mont:
f � .---I. b 0 kA, Qooc o \ 1v0,4 ovN
Name(Print) Current Mailing Address:
_„__.,k-. C341 S l 9 cps
Signature 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) X \ 3 Q 4 Check Number / p�7 )5
1 This Section For Official Use Only /
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
51 HENRY ST BP-2013-1009
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32-028 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-2013-1009
Project# JS-2013-001687
Est.Cost: $11300.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 065699
Lot Size(sq. ft.): 28009.08 Owner: HOPKINS MARTHA L&GILES S
Zoning: Applicant: BOB THIBODO ROOFING & SIDING
AT: 51 HENRY ST
Applicant Address: Phone: Insurance:
P 0 BOX 201 (413) 527-7663 () WC
NORTHAMPTONMA01061 ISSUED ON:4/30/2013 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 4/30/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner