25C-115 O�TYiAMFjo ""'�,
�815�Ch1ISC�9 _
DEPARTMENT OF BUILDIZG INSPECTIONS
212 Main Street • Muuic:i aI Builaig '\
INSPECTOR P 5.•`�z
Northamptoo, MA 01060
t'
HOME OWNER EXEMPTION ACKIINOWLEDGEMEN'T
'The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as I is/her construction supc. .-*Sor. T he 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 any 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 back ill).
sonotube holes (before pour). a rough building inspection(before work is
concealed). i-asulatioh inspection (if required)and a-final_buildina insyection. 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 occupanev
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
permits 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 me. y
Date
Address of work
location
r v
�. The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of In vestigations
600 Washington Street
Boston, M4 02111
www.massgov/dig
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leilibl y
NaMe(Business/Organization4ndividual):
Address:
u
City/State/Zip: Phone.m: L(
Are you an employer?Check the appropriat box:
. I am a general contractor and I Type of project(required):
4
L❑ I am a employer with ❑
employees (full and/or part-time).* have hired the sub-contractors 6. [D New construction
2.eI am a sole proprietor or partner- listed on the attached sheet. 7. (1 Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers' comp.insurance comp. insurance.:
required_] 5. 7 We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No 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.❑ Other
comp.insurance required.]
Y aPP ican a c.ec oox must a-a tz out a section :ow s wmg their workers'compensation policy- ormatim_
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
,Contractors that check this box must.attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance far my employees Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investisations of the DLL for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
S�
D
M tye r *� --
ate• L Q
Phone#: \p
LOther only. Ito not write in this area,to be completed by city or town qui-ciaL
Town: Permit/License
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: Phone 7:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: [�� , (j !
_ License Number EA
Address C7 Expiration Date
d d.'�
Signature Telephone
,
9e l7eaisfereil dome TmaiorrenteiitiContiracfar- <_ Not Applicable ❑
Company Name Registration Number
�— C
Address I Expiration Date
Telephone Sd•�`-1(��,3
SECTION 10 WORKERS'COMPENSATION,INSURAN'CEAFFIDAVr.r(NC 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 'ng permit.
Signed Affidavit Attached Yes....... No...... ❑
IM -��
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-vear 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 buildine 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
ECTION 5-DESCRIPTION OF PROPOSED WORK(check aft applicabil
ew House ❑] Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
,ccessory Bldg. ❑ Demolition ❑ New Signs [[D] Decks [Q Siding(C]] Other[o]
rief cription of Proposed
Vork' `S C vr% S�,h
,iteration o exisfing bed o,m Yes No - Adding newtedroom Yes No t
Aached Narrative Renovating unfinished basement Yes ___No
'fans Attached Roll -Sheet
a ltl�tev�locts and oadd�tron E .exfstcncttosesc�rotnpCeteE�eo�fo €crict:
Use of building:One Family Two Family Other
Number of rooms in each family unit: Number of Bathrooms
Is there a garage attached?
I. Proposed Square footage of new construction. Dimensions
Number of stories?
Method of heating? Fireplaces or Woodstoves Number of each
I. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
t. Type of construction
Is construction within 100 ft.of wetlands? Yes No. Is constructon within Yes - No
Depth of basement or cellar floor below finished grade
c. Will building conform to the Building and Zoning regulations? Yes No.
Septic Tank City Sewer Private well City water Supply
SECTION'7a-OWNERAUTHORIZAT)ON-Tt3 BE CpMPLETED WHEN
DWNERS.AGENTOR,CONTtZACTOR APPLIESrFOR StJILDING ,ERNfIT
4Z r as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters a ative to work authorized by this building permit application.
&gnaturli of Owner Date
- ---- _.------�----,-- ,as Owner/Authorized
Agent reb &-ciare 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 the pains and penalties of peedury.
ZX17 rt ��O %,l - --
Print Name
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
Rear
Building Height
Bldg.Square Footage
Open Space Footage
('ion area minus bldg&paved
Parking
#of Parking Spaces
Fill: ;
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
__.-�� in
IOW l 1 — � ---- -----
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O 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 O YES
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 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO O
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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
€kegartf ie n UW-vn
' � �-7
City of Northampton rams,
Pec T'
Building Department ejw- _
212 Main StreetewerfSe�tr7afirlcE - r
Room 100 er velE.L rcaE85�? •�- .• ':
Northam ton, MA 01060 rrexse o S rc[ura Ptans -- -
pho �13-5870 Fax 413-587-1272 L'laTkSeI?fans ,
APPLJ N TO C StJ ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
-SECTION,t,'. k ON
This sectron to be campfeteci byoffics}
1.1 Pro oe' Addres -
eflayDrstascf
E S>w Dis CS District_
SECTION-2 PROPERTY OWNERSHIPfAUTHORIZEDrAGEkT
2.1 Owner of Record: 11 i
Name(Print) Current Mailing Ad ress:
Telephone C Q °�
Signature ,
2.2 Authorized Agent:
C4 �4
Name(Print) Current Mailing Address,
ASS a10�
Q - l a (/ 13 S `1 -D 3
Signature Telephone
SECTION:3--EST IMATEa-CONSTRtJE:TI'ON CO3TS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1_ Building -(4-�Building Permit Fee
2. Electrical tb�EstimatedTotat Cost of
Construction..from(6)
3. Plumbing Building.Permit F'ee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number zn
T his Section-For OfficiaY.Use On!
Building;Permit Number. Issued'
Signature_
Building Commissioner/Inspector of Buildings Date
•. L
'�' BP-2008-0469
GIs #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-0469
Project# JS-2008-000696
Est. Cost: $6300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 152172
Lot Size(sq. ft.): 9321.84 Owner: SCHMITTLEIN LYNN M&MARK F
Zoning: URB Applicant: BOB THIBODO ROOFING & SIDING
AT. 64 GRANT AVE
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527-7663 O
NORTHAMPTONMA01061 ISSUED ON.1013112007 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE SLATE ROOF, PLY & 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 10/31/2007 0:00:00 $25.003077
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo