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24D-232 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 backlit!). 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 perform. work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper jermits 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 1 , 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 .;e Address of work A location • Oo so , • • ' The Commonwealth of 'Massachusetts Department of Industrial Accidents . ,. A =■''': fi, Office of Investigationg . . • .= ; 1., 7 4111:1=-. Iii 600 Washington Street ,..;-=.241=• i Boston, MA 02111 • ' f www.mass.gov/&a , -z, ' Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers - - ... Applicant Information _ _____ Print Legibly r V Name (Businesi/Organiiation/Indivirinni): S -- IR 1 n 0 ' - Xd.Clie;;; 5 -)" 7% 0 City/State/Zip: & b -\ :.) ----, ,, n Phoneg: --- ) a - 1 , c, _ sA-\ ,,, Are you an employer? Check the appropriate ' -Type of project (required): , • 1. E s - i I am a e m p l o y e r w i t h ( 4.. El I am a general contractor and I &DNewco]istruction have hired the sub-contractors employees (hill ancVor part-time).* listed on theAtmched sheet 7- 0 Remodeling 2. n 1 am a sole proprietor or partner- ship and have n.c..loyees These sub-cOntractors have s 0 D • working forme m my capacity. en:AlloyerAandhave workers : ., - --... -; - 9: faattildmii&liiifin Dskr workers' comp-. insurance required.] .- - . 5. 0 We are a corporation and its 10 -0 14 ctrical repairs or adcrtions 3.0 I am a homeowner doing all work officers haVe4z..ercised :their . 11.0 Pubing repairs or additions myself [No workers' comp. • right of exemption per MGL 12. Ell Roof repairs insurance required.] t • • . p. 152, § 1(4), and we have no • , 13.0 Other employees: [No workers' 1 - - • .. . • . comp. insurance reqUired.). . • - ' ' Any applicant-that checks box #I also fill out the section helots/showing theirimdcers' compensation policy information . 1. Homeowneri Who submit dtii affulaVitincficatin' g they are doing all work and theii hire outside contraCtorS must submit anew affidavit indica#ng such. :contractors th check this box nmstatiached an additional sheet showiiig the name of the subcontractors and *state vibetherornotthose-entities have employees. If the snb-contraciorshaie employeeS, they must providetheir wOriceis' comp. policy number. . ... • • - i gm an employer that is providing workers' compensation insurance for my einplayees. Below is the policyandjob site information. . Insurance Convany Name:7 • . \ •• Policy # or Self-ins. Lic. #: (-3 (1 6 l..) ( &)a,S 0 No-iLioll txpitition Date: - 3 -a-i- .1a.. - sco C Job Site Address: (:), \ ( c - t . - t-C..‘; . S '' City/Stafx/ZiP47421".1■k Attach a copy of the workers' compensation policy declaration page (showing the policy nunibek andeapiratiort date). Failure to secure coverage as reqiiiiid iiiittek.Seetroil'25AIVICIGL re. 152 can lead to the iii-JiiOilitOii)13:13in;iliinallies of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the fonn of a STOP WOXIC-OBDER and a fine of up to $250 00 a day against the violator. Be advised That a copy Of this statement maybe forWaided totheci , . . Eireitieiriciis Cif DrAlliile'6'6 : ---- 7 . 17"777.77,7, ....: do herehycerttb under t pains penalties ofiirjuryiltat the iiziornstitionprovkfidTabovairsin;jii4orret.' titre: ) i3 .' : : -: D : - - L '' #: s-4 , , ); ( c ., 3 izti use only Do not write izz this arerz, to be completed by city Or toWn'afficiaL Town: . . "- Pernut/License # uthority (circle one): 'Health 2. Building Department 3. City/Town Clerk 4. ElectricalInSpector 5. Plumbing Inspector . . 1: Phone #: I SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 6 S License Number \S S S\\\4c \ L `ate ya, Address / Expiration Date C ^ Signature Telephone 9 .:Reciisttred.FlamO.lmpio4etnei C+aiittietoiii . • , F ;H d _ .,._ . Not Applicable ❑ Company Name Registr Number E " V\ (AR S ck-- Address Expirati Date Telephone SP 1 b-' — SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affid vit 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 ❑ The current exemption for "homeowners" was extended to include Owner occupied Dwellinss 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 buildin2 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 1 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing I Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [I ] Decks [E Siding [0] Other [0] Brief t0 cription of 0 A Work: ,. ►� . i .. III alf■ IP 'V a 1 ' - ® > ` J p Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a if istimetiguse/atinvradditignlo existing fioi s na complete thefoHiawiiiq: 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, C i\\ \r" \U r 1\ L , as Owner of the subject property S - 3 hereby authorize ' 4c O to act on my behalf, in all matters relative to work authorized by this building permit application. Cm5 INV Ylii.JfilelAg 6 A.° 1 Signature of Owner Date I, C) 1 a �\D 0 k0 , as Owner /Authorized Agent herebye A eclare 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 or. pains and of perjury. ^ 1 � r b Print Name R -Ia)\` :- \VLIY0495-s cl ' C) 0 Signature of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information . r . . Existing Proposed Required by Zoning , This column to be f led innby ,, j Building Departm f no: 1 $$ 1, Lot Size 1.- . ,.,.. Frontage ._- .._._. Setbacks Front ? Side L R. L: r i i R: i _W , _. Rear = I Building Height i r 1 F Bldg. Square Footage ; 1 % 1-1 "" " , Open Space Footage , % (Lot area minus bldg & paved .,.._ _ ,J ? parking) # of Parking Spaces 1 1 m w, .4 _ , Fill: .� .mm_ s ,t i (volume & Location) i ' - -- ---- ----- 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:; j IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page; I 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 i Obtained ,Date Issued C. Do any signs exist on the property? YES 0 NO i IF YES, describe size, type and location: I D. Are there any proposed changes to or additions of signs intended for the property ? YES (3 NO 0 IF YES, describe size, type and location: 1 w 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 Q NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. RECEIVED City of Northampton t �� x41 ? i" , ' t: 41 Building Department �� °F f i .: : 212 Main Street ql , i .,,, r,, , ,:: gill 2 ` Room 100 Northampton, MA 01060 r e . 13- 587 -1240 Fax 413- 587 -1272 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 ' ; Map Lot - Unit Zone Overlay District Elm St." District " CB. District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: � ,( CatilPrint it,tr t9 iii(0 f r"os P 6.4-. Wo r - 1- hpup -f'a N Name (Print) Current Mailing Address': e tli -- .�nl Telephone Signature 2.2 Authorized Agent: 1361 T► i 1964 h 3 Ea.St Mc /est., EEs 7 /-1' Name (Print) Current Mailing Address: 1/3 - 667 - 7163 Signatur Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Offic 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) l' 5. Fire Protection ` / 6. Total = (1 + 2 + 3 + 4 + 5) ] \ r )--E) c) Check Number _ This Section For Official Use Only Date Building Permit Number: issued: Signature: Building Commissioner /Inspector of Buildings Date 216 PROSPECT ST BP- 2011 -1078 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 232 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- 2011 -1078 Project # JS- 2011- 001740 Est. Cost: $1200.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BOB THIBODO ROOFING & SIDING 065699 Lot Size(sq. ft.): 5880.60 Owner: MURPHY EDWARD J & CATHERINE M & MURPHY DIANE M ET AL Zoning: URB(100)/ Applicant: BOB THIBODO ROOFING & SIDING AT: 216 PROSPECT ST Applicant Address: Phone: Insurance: P O BOX 201 (413) 527 -7663 0 WC NORTHAMPTONMA01061 ISSUED ON: 6/22/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: STRIP & SHINGLE PORCH 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 6/22/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner