Loading...
16A-031 /1 - J 5/NV1 • 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 'hall 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, ° act as their own construdtion 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 inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. lithe 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 1, / mt gx rt, 0 66/0 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 S h e? /2-e3 1/ Address of work location 9 V S . P R'> /G . r L , eos, / e /05 3 ,, ' •,• ' • . - . . . , The Commonwealth of Massachusetts Department of Industrial ACciderits • , , Office of Ini • ' 600 Washington Street Boston, M4 02111 www.nzass.gov/dia , • .. , • - Workers ' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information - Please Print Legibly . -. • ,,i-.-1 Name pusinesitorgationandividuaD: , . . . .-,.., :. • : - - -Address: ,- . • ' . . City/State/Zip: • - . Phone It: • - - . . p Are you an employer? Check the appropriatebox: • . •Type of project (required): / 1.0 I am a employer with , 4•. 0 I am a general contractor and I 6. 0 New coistruCtion have hired the sub-contractors employees (frill and/or part-time).* 2.0 I ain a Sole proprietor or partner- listed on the'atached sheet 7. 0 Remodeling . . These sub-contractors have ship ond have no .,loyees .8. D Deinolidon • . . dae workers - • . - - - working forme m any capacity anhv k . O . sci=i [No smirkers" comp. insurance 10.0 repairs or additions required.] , 5. 0 We are a carpioration and its officers haVe-Sxercis ed their . 11.n pitiObing repans* o additio 3.1;i I am a homeowner dOing all work ffi myself [No workers' comp. - . Hen of exemption per MGL 12.0 Roof repais . - insurance required.] 1 ' . . 152, §1(4), and we have no emp N 9 wc 13 0 E . :: dthet , • - .. , ' '. • - applicant Mat checks box #1 fill out the section below showing their compeimation policy informatiow t Homeownera who submit thia affidoit.inffidating they are doing all weak and thtii hire outside contraetori must submita new affidavit indicadag such_ Contractors that check this box must attached an additional sheet showiag the name of the sutkontractors and 'sea' e wietherornotthose-artities have entployets. If the sub-contractors hatie employeet, they mast provitietheir wOricers comp poky number. lam an employer that isproviding workers' compensation insurance for my einplOyees. Below is the policy itzdjoh- site information. , - . , • . • - - Insurance Company ame: • - - . • . . . . . • • . - Bxpiration Date: - ' • .• I ' Policy # or Self-ini. Lic. #: - . . . . . . . . • . . . Job Site Address: . . : . • • ' ' City/State/ZiP:'. • .. . . • r - _. . Attach a copy of the workers': compensation poliey declaration page(showing the policy nninber. and expiration date). . . Failure to secure Coverage as reqUired $eCn lead to th e flip ii iiii. iifi iieiti* es of a fine Up to S1,500.00 and/or one-year itoprisonme4 as well as civil penalties in the form of; STOP WORK-ORDIER. and a fine • of up to S250.00 a day against the. yiolatirs. Be advised that a copy Of this statement may be forwarded to iiii.OtriCeof - avtintiOnl - c - iftlie -- ix - A -- liii - iAiiIa'ai' . ;iLiVL .'-- - "-- --: ----'"--..-- 7"1 _ pre - ncler_ ' the .", • ,, , . - , .' • of:perjury that the rnfonnationprondellaboOgitttheaniliorrpct _ . , , alimi,.L. "' • . ' . . a ate- -..'- ./ F Z°// . . Signature: ... • Phone #: C 3Z0 - 1 9 rt9. lb ‘ - •.- r • ' - . • • . . : - OffiCial use only. Do not write in this' area, to be completed by city Or torirnOfficial , ., . . City or Town: . I Authority (circle one): .- Permit/License # • ... . :1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalIttspector 5. Plumbing Inspector 6. Other Contact Person: ' - . Phone #: • - - . ' • SECTION 8 - - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9. Realsteied•Romealtrfti eltieiitt:G+3inti `c Mag ._; . 1e : . >gg,. Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c.152,125C 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 building 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, d Local n nd State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or (Mors ❑ Accessory Bldg. `y° 1 Demolition ❑ New Signs [D] Decks [Q Siding [D] Other [0] Brief Description of Proposed Y-111) Work: C -5-61.6P QNS7-4eVeT �o G- ED 4/ / v�TJ�OlUO er1 Alteration of existing bedroom Yes X No Adding new bedroom Yes No Attached Narra ' - Renovating unfinished basement Yes No Plans Attach- • Roll - Sheet 04, Ii" ...... an l air al i tip i' + riq r s n c� n pl " i 'fioii+ win 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 la - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date ,24/e X 4. /&"6 , 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 of perjury. "M//, ' 4. /)66X' Pnn e Signature of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplet= fo ati. 7 Existing Proposed Required by oni This column t. fill , by f I+ Building Depa f 1 i. ' Lot Size I 3: S cge 1 ` _ t �. " "" Frontage / 2 5" 1 • 7S ' w Setbacks Front s .c ' E 1 r Side L: R: i L:i� R: Rear = [60 `` , Building Height P 4 EZE [_..__... Bldg. Square Footage Open Space Footage % 1 (Lot area minus bldg & paved ? �._. parking) # of Parking Spaces J Fill: (volume & Location) t .. A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO ta: DONT KNOW 0 YES 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 i Pagel ( and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 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 0 IF YES, describe size, type and location: 1 "" ki D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO IF YES, describe size, type and location: 1 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. \ • - City of Northampton � wilding Department \ 212 Main Street :,f ,fi . ��.. �.. - Room 100 E h t of 0* ;,s Northampton, MA 01060 • phone 413 - 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 //Z-15 S 1 Map Lot Unit '2719 7/t "5'3 Zone Overlay District Elm St. District J -° CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: / 1.0(1A1— /1 /9.' /,E ,zw 'o p G'• . G (` ‘0/2 /=� o%I,G 1 re. U/06 2 Na rint) Current Mailiny�ddress: C5/ / S 3 Z //7 �d Telephone Signature 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 completed by permit applicant 1. Building / +"OO� ., � eed (a) Building Permit Fee 2. Electrical (b) (b) Estimated Total Cost of 4 e Construction from (6) 3. Plumbing 6 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2+3+4 + 5) -AY r /, .6 Check Number 9 f This Section For Official Use Only Date Building Permit Number: "Issued Signature: Building Commissioner/Inspector of Buildings Date File # BP- 2011 -0952 O f > APPLICANT /CONTACT PERSON MOGGIO MARK A & ANN - MARIE a;'� y ADDRESS/PHONE P 0 BOX 60127 FLORENCE (413) 320 -1780 0 (j PROPERTY LOCATION 445 SPRING ST 16A PARCEL 031 001 ZONE URA(100) / /WPIWSP S � THIS SECTION FOR OFFICIAL USE ONLY: �,` !.G i' PERMIT APPLICATION CHECKLIST U ENCLOSED REQUIRED DATE CI ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 0 7C' Fee Paid 6 ((r3l ` Typ of Construction: CONSTRUCT 24 X 16 SHED W /BATHROOM JV OT TO E t�J a s %' �wf (�. �'� New Construction or Sta.(' 0 s'PF3,EE Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF RMATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER: § Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission _ Permit DPW Storm Water Management Demolition Delay Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information.