Loading...
38D-027 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,lo 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 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 •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 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 Date Address of work location S • , '.. • 4 T • ' a . . The Commonwealth of Massachusetts Department of Indus ACcidents • , ii ............„ ifi - : ' Office of InivstigafionS • . 600 Washington Street • Boston, MA 02111 . . •••■■-.... IMP . www.mass crovidia .- -- -0 • -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers - - ... Applicant Information - Please Print Leithlv -- ame (Businest/Orron/Individua1): /41d cy-, irvi,r, ,...._ 0 ' ciLy i j • • Address: p (1,5c) ,`.2..,0 1109/d...C___V) V 1 I ( 1 e ) .-.- 91 4 City/State/Zip: - . 3 6 Phone.#: 1.--/ i , b n —1 -/ 196), Are you an employer? Check the appropriatebox: • . .Type of project (required): i 1.0 I am a employer with 4•. 0 I am a general contractor and I s. 1:;frP co " ' 'on loyees (full and/or part-time).* have hired the sub-contractors 2_1Z12 a sole proprietor or partner- listed on the:attached sheet. 7. 0 Remodeling These sub-contractors 4ve. S. 0 DanOlition . ship and have no iiloyees • working for me in any capaaity. 00)19.4P.glitave Workers' - - -., _ -,' - • - - 91:111nildbig'iditiOn. required] , . 5. 0 We a re a corpotation and its 10.0 -Electrical repairs or additions • • 3. 0 I am a homeowner doing all work officers haVe4rethised their 11.E1 Phi:tubing repairs or additions . myself [No workers' comp. - right of exemption per MGL 1-, •,.. ,- 12.11 Amor repairs insurance required.] t • : : c. 152, §1(4), and We have no • . etaphriees. No workers' 13.0 Other . = .. - • •Any applicant that checks box #1 also fill out the section below showing theirWorkers" compensation policy infamatiOn. 1 ' Homeowncra who submit this affidaVit.incrrcating they are doing all work and then hire outside contraCtorn must submit anew affidavit mdzcalmg such. :contractors that OvIt-ir this box mustattached an adcfitianal sheet showing the name of the subcontractors and State wirethernr not-those amities have , . • einployecs. If the sub-ccattracinrshaVe employees, they must provide their workers comp poky number. • . - ' - I am an employer that isptoviding workers' compensation insurance for my einplivees. Below is t h e Polk,' and jobsite information. • . - . • . Insurance Company Name: • • . . . • - . • . . . Policy # or Self-ins. Lic. #: Expiration Date - - • • • . . . ,Toli Site Address: - ' : ' . '• City/State/Zip:'• . - . • - • - • Attach a copy of the workers': compensation policy eclaration page the policy munber and date).. Failure to secure coverage as reqmrd Seetrott25A 152eiii lead to the iinpoiiiiiin oriiinil penalties of a fine up to S1,500.00 andfor one-year iniirdsonment as well as civil penalties in the form of a STOP WORK-ORDER. and a fine • of up to 5250.00 a day again.st tii violator Be advised a copy of this statement may be fOniyardeiliU the Office Of - ffvertiiiitibiis - iiftli - iIDIA'Tiiiiiiiiit6' 4: 8g '6iiiiiiii ' --- - ' . . ''*---. : 77 :---_,..- ... : -- : ' , ..r. . 7 : ...„- fie : Itereby .1111.47 tbe pains•and penalties ofperjurythatthe infornuttionprovideilib ay.kii.thte.aral,Carrori ' _ . Signatia-e: .a.-- F - * - - ' : l - ' ' ' '76ate: t - --- t..:. . i ( . . - , _ Phone it: ili 3 — • V 7-i / q : ' - . - . • . "Official use only. Do not write in this' dria, to be citiipleted by cay or town'o jrzczaL• I • - , : ' : . . City or Town: "- Permit/License # • ____ . Issuing Authority (circle one): :1. Beard of Health 2. Building Department 3. City/Town Clerk 4. ElectricalIit.spector 5. Plumbing Inspector 6. Other . Contact Person: Phone #: . • • K SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 46o7f bl License Number go, f) Q/ 7 6 - i ��.. Address Expiration Date / 3 ( a F � �S - 9 1 c Q l c- Signature Telephone 9: Home! m 'riivemeritil±ontt c #or Not Applicable ❑ tai � � . _ � .,.,� a k.�.� � ..,. .., PP Company Name J Registration Number pi°. box es( 1-e:9( 1 A- 3 � i3 Address c� '1 Expiration Date ' Q3g Telephone 65 / — IOC SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.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 building permit. Signed Affidavit Attached Yes 17 No ❑ F me (wrier ion 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, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature r SECTION 5- DEpRIPTION'OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing E Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [[31 Siding [ ❑] Other [❑] Brief Description of Proposed Work: Nz-W 1 &/ X ( 4; ' b rCV Alteration of existing bedroom Yes V No Adding new bedroom Yes ✓ No Attached Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roll - Sheet sa Niii sous flc r.. iddit6"i zi$tii ii _hOUsina4 ciml 14'11 hfollc w rhq: 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 1, Au��o r' f �I , as Owner of the subject prope hereby au horize id-_V.1 E. t.w*Ve` I CIS to act on y behalf, in all matters relative to work authorized by this building permit application. NI - e(' (t( n ature o Owner ate I, A (c E W1. v -- i c i ' Z -_, , 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. Print Name t 17; -- l 1 Signature of Owner /Agent Date 3t-cD7 --t- sg D - i 0 ,:n . . . . . i Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Info •ati. Existing Proposed Required by Zonin 0 , 4 Lkb le . This column De be fine• by t 1 1 Building Department i s i ' Lot Size I , Frontage '' J O Setbacks Front u--_ I i l Side L:' R: € L: R:= Rear Vi ' Building Height , t 1 ! �_ t Bldg. Square Footage % F-1 1 I 1" 1 Open Space Footage 1 t (Lot area minus bldg & paved L , , I L... parking) # of Parking Spaces i # i Fill: �..�w � (volume & Location) I • A. Has a Special Permit /Variance /Finding r been issued for /on the site? NO 0 DONT KNOW YES 0 IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES Q IF YES: enter Book Page and /or Document # ^ B. Does the site contain a brook, body of water or wetlands? NO Q"DONT KNOW Q YES 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 Q NO IF YES, describe size, type and location: — w E D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO IF YES, describe size, type and location: ..rt E. Will the construction activity disturb (clearing, grading, ex vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Y } tires City of Northampton �� ���� �� �� Building Department O 212 Main Street Room 100 : e [±EPT. OF BUILDING INSPE • Northam MA 01060 k "�THAtAPTON,MA0 ° a - m 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 "! dirt pGl C n S'! Lot Unit /v,.. r r h P1 g vi j ."1 /9- - zone Overlay District Etm . St " District CB District • SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: AI ?Soil 13E/Vi Name (P ) - Current Mailing Add s: �, ())_ ji /��p / Telephone ature 2.2 Authorized Agent: A-fden _►..- w-,x P1 a, 6 ©x (.)_9 1 lo._)denvi - IIe Name (Print) Current Mailing Address: c Signature Te phone SECTION 3 - ESTIMATED CONSTRUCTION COST S Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee )N L1 ©C) , pn 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 4 $e' 6. Total = (1 + 2 + 3 + 4 + 5) , � ®© , O Check Number 7t This Sect For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date Y * Massachusetts - Department of Public Safetc Board of Building Regulations and Standards Construction Supervisor License ■ License: CS 68078 ALDEN M EMRICK PO BOX 291 I H AYDENVILLE, MA 01039 ;111 , Expiration: 7/6/2012 ( omrnission Tr#: 31947 , Office -o ons me Af rss $_siness egu a * HOME IMPROVEMENT CONTRACTOR m _ Registration x;123661 Type: tly Expiration 312512013 DBA A. ". - EMODELINGt Alden Emrick 90 MOUNTAIN ST a �_ _ Haydenville, MA 01039 Undersecretary • 1 VVil --- I lliii � R ,, ,,14 % 1\ -1: ......r 1110 -- 001110 _..__.,---- t y� / \ N eSr ik fV r'v P----LD _ _xt t �y .. Hou.s c= lic:,_,., 3 > —1 -. j I QpnScd pecK I 1 ly'x -16' 1 V I 0 A O� -(- wu' e v oa d 1 1 00 v ° I -1 r 75 File # BP- 2011 -0812 APPLICANT /CONTACT PERSON ALDEN EMRICK el9Pti ADDRESS/PHONE P 0 BOX 291 HAYDENVILLE (413) 658 -4192 O PROPERTY LOCATION 14 HAMPDEN ST MAP 38D PARCEL 027 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid a G - 7v � 46 Typeof Construction: CONSTRUCT 14 X 16 DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 068078 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN.FOJ MATION 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 ignature 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. 14 HAMPDEN ST BP- 2011 -0812 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38D - 027 CITY OF NORTHAMPTON Lot: -001 PERSONS CON 1'RACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Deck BUILDING PERMIT Permit# BP- 2011 -0812 Project # JS- 2011- 001334 Est. Cost: $2400.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ALDEN EMRICK 068078 Lot Size(sq. ft.): 5619.24 Owner: MALLOY ALISON F & DAWN GELLER Zoning: URB(100)/ Applicant: ALDEN EMRICK AT: 14 HAMPDEN ST Applicant Address: Phone: Insurance: P 0 BOX 291 (413) 658 -4192 () HAYDENVILLEMA01039 ISSUED ON :4/15/2011 0 :00 :00 TO PERFORM THE FOLLOWING WORK :CONSTRUCT 14 X 16 DECK 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 $50.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner