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38B-074 i 1 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 • • • • • - • • - y '. • .r. cess 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 — — permits-in-conjunction to- the.building permitissued,_ 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 f I, / understand the above. ( ome owner /resident's si_ • ature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Address of work location e r . . - e .. The Commonwealth of Massachusetts Department of Industrial Accidents • 1 =tilitr—=.7 1 Office of Investigations 600 Washington Street . vat; • ....., da' Boston, MA 02111 • ,..., .......-.., wwv.mass.gov/dia gag -r, -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: / Type of project (required): i 1. 0 I am a employer with 4. 0 I am a general contractor and I 6. 0 New constructiOn employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. 0 Remodeling 2. 0 I am a sole proprietor or partner- These sub-contractors have ship PTO have no e...:doyees 8. 0 Demol ' working for me in any capacity. employees and have workers 9. El Building addition • insoranre.: [No workers' comp. insurance - comp. required.] 5. 0 We are a corporation and its 10 Electrical repairs or additions 0 3. hd i rp I am a-omeownereing-all-work o_factulaxe_x_ercis_ed_their— —ILO-Plumbing repairs or additions rieit Of exemption per MGL myself [No workers' corop. 12. 0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.) 11E: Other *Any applicant that checks box #1 must also fill out the section below showing their workers compensation policy information. t florneowners who submit this affidivit 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 mustprovide their workers' cotnp policy number. • lam an employer that is providing workers' compensation insurance for 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 SI ,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a -n4.• of up to 5250.00 a day against the violator. !le advised that a copy of lids statement may be forwarded to the Office of Investizations of the 1DIA for insurance coveraee verification. I do hereby certify Lind = the pains and pen di s of perjury that the information provided above is true and correct._ 1 Ai If rior Ark211111arlivAL. D te • . 'Lure: .0// §... .r . ' W 0 . . • 4 '''' — Phone #: • Official use otzly. Do nth` tv it thifa be eompkted by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1.Soard of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 1. 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.'Reaistered HOmelinpiciverner t ontrae , ..n, ! ,., ;` .... Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone _ SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) J 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 "homeovv ers" was extended to include Owner 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 o ampton r +mantes; a e I ,. ,. ,,,• •; _.i.. • _ .. , serener -a1- Laws - Annotated. 774.-Ife_ Homeowner S SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition NI; Signs [Ej Decks [C] Siding [0] Other [0] /Work: Description of Proposed (.13 ' l4) I e I oc Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. lUtteiiitiOute arid oi addit ontoxexistitirl iiousinq,. omdlete fonow m:: 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 , 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 I, 6 \)el' , as Owner /Authorized 9 hereby Agent ( 1,3 declare that the statement 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. du ( 69 \De1d' . Print Name Signature of nerlAgent ` Date i. l 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 :1-._-....._ L:._____ R:` Rear Building Height ; mm .._. Bldg. Square Footage ..`__ % # _ Open Space Footage % __. (Lot area minus bldg & paved m ,_ n :_____j parking) # of Parking Spaces -M•-- _ °--- °° Fill: i (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 DONT KNOW 0 YES 0 IF YES: enter Book Paged` and /or Document # `�„ B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: " - 17Are tthi`ere an ro'= os es to or a pio o si ns nt f ed t15e •ro ert ? YES 0 NO 0 YP P g P P Y• 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. . y City of Northampton StWt s ofl n rt .f e Building Department s a ae 3 a� ,- 212 Main Street Se 's Sep, � #rt� [ tv,� . Room 100 W iKA iiab g m �� ' F , i , Northampton, MA 01060 p�, .t w� phone 413 - 587 -1240 Fax 413 - 587 - 1272 ©I te°I? �� � 't APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: ( G rl 5 - Map Lot Unit '!:Zone Overlay District ' .Elm St District CB District .SECTION .2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 0 .� -- � , t -. - 5 f , l (Print) — (! \ tell C 7 5 Q 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone S CTION 3 - ESTIMATED CONSTRUCTION COSTS: —7 em Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building Jo co (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 d V6 *55" This Section Fur Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspectorof Buildings Date 221 SOUTH ST BP-2010-0220 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B - 074 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- 2010 -0220 Project # JS- 2010 - 000274 Est. Cost: $3000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 21649.32 Owner: UHLIG ROBERT P & CYNTHIA M Zoning: URB(100)/ Applicant: UHLIG ROBERT P & CYNTHIA M 7' 221 S(1l NTH ST Applicant Address: Phone: Insurance: 221 SOUTH ST (413) 584 -5078 O NORTHAMPTONMA01060 ISSUED ON :8/26/2009 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: 0 PC ci -2,07.0 q A„. 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 8/26/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo