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17C-108 (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, 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), 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 insvections 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 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. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents -� Office bf Investigations `� 600 Washing-ton Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print Legibly Name (B usiness/Organization/Indi vi dual): \)�� , n L _ Address: , I F )n C4 511 City/State/Zip: J Phone#: Are ou an employer?Check the appropriate box: Type of project(required): 1.Z] I am a employer with 5-1 4. E] I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.F_1 I am a sole propri etor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, F-1 Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp. insurance. required.] 5. F-1 We are a corporation and its 10.0 E ectrical repairs or additions officers have exercised their 11. lumbing repairs or additions 3.❑ I am a homeowner doing all work � P myself. [No workers' comp. right of exemption per MGL 12.[V Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.) *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t 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 for my employees. Below is thepolicy and job site information. Insurance Company Name: Gx �O�' Policy#or Self-ins. Lic.#: 1- , V o Expiration Date;�­1 v Job Site Address: City/State/Zip: l')r Attach a copy of the workers' compensa ion policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalises of a fine up to$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$20.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature:/ Date: © r(1• C?' Phone#: ' O fcial use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: d Not Applicable ❑ Name of License Holder: d o O S' �j License Number s � � Address Expiration Date 3 57 Sig ature Telephone 9.Re istered Home.lm rovement Contractor , .., . . ..,. Not Applicable ❑ Company Name Region Number Address Expiration Date � + l Telephone -- SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(S)) 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 builng permit. Signed Affidavit Attached Yes....... No...... ❑ 11. —Home ©weer fxempfia>r� 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 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. AN 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) D Roofing Or Doors 1`7 Accessory Bldg. Demolition 0 New Signs [0] Decks [❑ Siding[O] Other[p] Brief De ription of Proposed Work: �"�6J2 ©ln-C �,.� � `Qs � [T i b n Ya Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If Newhouse and or addition to ezistinq housing compCete the followinq 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 stones? 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. \j as Owner of the subject property hereby authorize ca to act on my^behalf, in 0 m -ers)re tive to work authorized by this building permit application. Signature of Own(Zr/--, Date 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 oCry, � -7 o Print Name per, r Signature o wner/Agent Date Section 4. ZONING ALI 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...., Rear Building Height ° Bldg. Square Footage % Open Space Footage % (Lot 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? NO 0 DONT KNOW 0 YES IF YES, date issued:' IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONTVKNOW AY 0 YES N0..._. IF YES: enter Book Page'' and/or Document#! B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW () YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued C. Do any signs exist on the property? YES NO 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. 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. Department use orfl City of Northampton Sta iof fern t � ' Building Department CurE Euf©nvewayrmtf 212 Main Street v Availability SewerfSepUc Room 100 .` UJarlWellAvaitabihty" Northampton, MA 01060 T3-$ Tw' etso€StructuratPlans phone 413-587-1240 Fax 41� 7-12k P a(Sif Ions ter Spe APPLICATION TO CONSTRUCT,ALTER,REPA,R,RENOVATE OR'.LSElgrOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office W., ��\ Map Lot Unit W., c � S Zone Overlay District V1 r''--°„VA Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: (1 L D Name(Print) Current Mailing Address: Telephone Sig ature Sac( (45�'In 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted 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 =0 +2+3 +4+5) C) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date v BP-2009-0467 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-2009-0467 Project# JS-2009-000633 Est. Cost: $4000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BOB THIBODO ROOFING & SIDING 152172 Lot Size(sq.ft.): 16117.20 Owner: KLOC STEPHEN S III&LISA J Zoning:URB(100)/ Applicant: BOB THIBODO ROOFING & SIDING AT: 87 HIGH ST Applicant Address: Phone: Insurance: P O BOX 201 (413) 527-7663 () WC NORTHAMPTON MAO 1061 ISSUED ON:1012812008 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE EXTENSION 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 10/28/2008 0:00:00 $35.00785 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo