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36-100 (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 ekemption,-to act as'their own construction supervisor,to be aware that by doing so you become responsible for compliance with state building codess 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 �ermits 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 ca 11 to schedule all required building inspections necessary for the building permit issued tome. Date Address of work location � T The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigationg 600 Washington Street Boston,MA 02111 v ' www.mass gov/din -Workers' Compensation Insurance Affidavit:Builders/Contractors%Electricians/PIumb.ers Applicant Information Please Print Legi'bIv Name(Business/OrgmAiationandivi&w):. Address: E �- - V�(A2 lie �= City/State/Zip: Phone Arou an employer?.Check the ropriate•bo=: Type of project(requi ire d):. 1. I am a employer with 4-- Ej I am'a general contractor and I employees(full and/or part time).* have hired the sub-contractors 6 New corist action 2-Q I am a'sole proprietor or partner- listed on-the_attached sheet. 7. D.Remodeling ship'ld have no a=loyees These sub-contractors have. .8. Demolition working for me is any capacityiayces and Have workers' ... r0stua•nce#. .. �• H a�ditioII workers COMP,:Insura=__ - Coit>Q - =_ _. re ed 5. E] We are a coipoiation and its 10. Electrical repairs or additions l officers have xercised their 3.0 i am a homeowner doing an work -.- r 11.- Plumbing repairs or additions myself o workers'comp. right of exemption per MGL 12: �.Roof repairs insurance required.)t c: 152,§1(4);and we have no employees:[No workers' 13.0 Other ' ' . - comp.insurance regtr¢ed.�. . ;Any'Any applicmt that checla box#1 nasst.also fiII out the section below showing tiies�iiorlrers con�msatian paficy mfonrad an who submit this affdavit.iadicatng they are doing an work and thm hire outside contactors must submit anew affidavit indicating such. =Contractors that check this box mvst.attached an a dditional'slied showmg the name of the sub-contractors and state whether_•or notihose.entities have employees. If the sub-contractors have employees,they must provide their worlds'comp-policy number. I ant an employer that u providing workers'camp anon insurance for my employees Below is the poficy and job:site .:information. / _ - Insurance Company Name- NlFre_�� 1,Y Policy#or Self-ins.Lic.#: © b Liq 0�. Expii-ation Date., ` Job Site Address: City/Stafe/Zip. Attach a copy of the workers'.compensation policy declaration page'(showin9 the policy number.and ezpiratton date). Failure to secure coverage as reginred irides Section 25A ofMGI c 1'52 can lead 16 die imposition of"camnal penalties of a fine up to$1,500.00 and/or one.-year.impnsonmeut,,as well as civd.penalties is the form of a STOP W9RR O VER and-a fine of up 250.00 a-day against the violator Be advised that a copy of this statement may be forwardet :to the Office of Investigations oftfie bIA formsurance coverage eiification-~ --- _ _, �_� Tom^ w. Ido hereby*cert{fy-under the p p. fp4*y that"the irrfornrahonprovidedlrbavE tstrtce aad�carrect airs and enalties o_ Sit nature: –bate CA Phone 0: — O 'ctrl use onl . Do not write in this are to be co- feted b Official y a, mp . y city or town afficiat City or Town: - _- PermftUcense# Issuing Authority(circle one): ."1.Board of Health 2.Building Department 3.Cityfrown Clerk .4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Nod/t Applicable ❑ Name of License Holder: \ License Number C Address Expiration Date Signature Telephone 9;. ,e isten do of ie eri ireniertt:,Eonttac`or£ n q ,o, �.. _ �_.. �- n ..r s.. Not Applicable ❑ d�� \ �� Company m \ M... Registration Number N(aae 9 Address (( Expiration Date Telephone �V 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 buildi g permit. Signed Affidavit Attached Yes....... IV 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 E] Replacement Windows Alterations) Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[0] Other[l7] w.v LO Brief D ription of Proposed r--- Work: �, L C Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sav°lf -0 9 #> r s�nac co i is e� fal a r: 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-.T6 BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property r hereby authorize ,\ to act on my; eaa , ll ma tters relative to work authorized by this building permit application. Signature of Owner Date C 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 anq penalties of perjury. 6� c� Print Name ,\\��y Signature of Owner/Agent 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 Lot Size Frontage Setbacks Front Side L R:[ ' L:r_.�_.._...i R:? _ Rear Building Height e- -- Bldg. Square Footage Open Space Footage % (Lot area minus bldg&paved -kin #of Parking Spaces !---•- Fill: i 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 Page 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 Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO 0 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 Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. tj of Northampton, ; x � kl kR _ ilding Department — 212 Main Street Z 2 2OI4 Room 100 hamp ton, MA 01060 ohons 13- 87-1240 Fax 413-587-1272 Z bing& as Inspections 0' -n 4!1.0 n 0',060 n CATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING n 0 �h� D EC 1-SITE INFORMATION D This section to be completed by(office 00 .1 PdQ tv Address: z Map Lot 'Unit I Zone ' Overlay Drstr�ct Elm St.District GB.Dstrict SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Prtj, Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name(PrinfT Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit 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) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of!Buildings Date 973 BURTS PIT RD BP-2014-1082 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36- 100 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-2014-1082 Project# JS-2014-001856 Est. Cost: $4000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BOB THIBODO ROOFING & SIDING 065699 Lot Size(sq. ft.): 27834.84 Owner: POWERS GARY R&PATRICIA E zonine: Applicant. BOB THIBODO ROOFING & SIDING AT. 973 BURTS PIT RD Applicant Address: Phone: Insurance: P O BOX 201 (413) 527-7663 () WC NORTHAMPTON MAO 1061 ISSUED ON.•412212014 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 Sivature: FeeTyne: Date Paid: Amount: Building 4/22/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner