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23A-031 (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 consf , cts more than one home in a two -y.. period shall not be considered a home owner." The building department f. the City of No I . pton wants person(s) who seek to use the home owner exemption, t a . ct as their o , construction supervisor, to be aware that by doing so you become respon 'ble for ompliance with state building codes and regulations. The inspection proce re ires that the building department be called to inspect work at various stages, whic. • clude foundation /footings (before backfill), sonotube holes (before pour), , ough , uildin2 inspection (before work is concealed), insulation inspe on (if rea ' ed) and a final building inspection. The building department requir- s these inspectio before the work is concealed, failure to secure these inspectio can result in failure obtain a certificate of occupancy until the work can • ins sected. If the homeowne es other trades to perform work - lectrical, plumbing & gas) the homeowner wil a responsible to make sure that the tra es hired secure their proper permits in conjunction to the building permit issued, and ' at they get their required inspections. Failure of the individual trades to secure the pe I 'ts 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 ..„7. "-" Department of Industrial Accidents Y- Office Of Investigations ' ' 600 Washing on Street Boston, MA 02111 `,•_; ., _ www. gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information PIease Print Legibly • Name ( Business /Organization/Individual): Address: City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. C I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. E] New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have g, 0 Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance. required.] 5. fl We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13. 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 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 trp to $1,500. and /or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 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. 1 Signature: Date: Phone #: Official 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 Clerk 4. Electrical Inspector 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. Registered Improvement Contractor , , ,. ` ' ,I,': °"_ , _. ,., Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG.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 ❑ No ❑ Home Owner E 11. ieimption The current exemption for "ho?negwners" was extended to include Owner :ccupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does • of possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition' Section 1083.5.1. Definition of Homeowner: Person (s) who own :.arcel of land on , hich he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, . - • ched or c etached structures accessory to such use and/ or farm structures. A person who constructs more than one hom• "I , two - year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, o fo acceptable to the Building Official, that he /she shall be responsible for all such work performed under the b • ding per' As acting Construction Supervisor your presence o e job site will be uired from time to time, during and upon completion of the work for which this permit is iss d. Also be advised that with reference to Chapter - (Workers' Compensation) and - • • .ter 153 (Liability of Employers to Employees for injuries not resulting in Deat. of the Massachusetts General Laws Annot. -d, you may be liable for person(s) you hire to perform work for you under t. 's permit. The undersigned "homeowner" certifi-. and assumes responsibility for compliance with the State : uilding 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) n Roofing n Or Doors i] Accessory Bldg. ❑ Demolition New Signs [O] Decks [I Siding [O] Other [O] Brief Description of Proposed ' Work: 06 MoL(St� '�laCliw l Ri d 6ARAkE Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete th followi a. Use of building : On amity Two Family Other b. Number of rooms in each fame nit: Number of Bathroo • c Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? Irr f. Method of heating? ' - places or Woodstoves Number of each g. Energy Conservation Compliance. Massch- k Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of - ands? Yes No. Is construction in 100 yr. floodplain Yes No j. Depth of basement or cell -r 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, 47 poi ab 4-/01 ff- A ff ,totY,2 , as Owner of the subject property hereby authorize ,tZ22!/Lt , .4 � to act on my behalf, in all matters relative to wo ithorized by this building permit application. Signatiireof. Owner __ - _- - -____ - -__- -_ _--- ___ - -_._ Date 1) 1, -4 , as Owner /Authorized Agent hereby declare t t the stat ents 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. r _ _ I . fit'" `f Print Name # ij _ 40 w Signature of Owner/A,: t / Date 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: Rear Building Height °° Bldg. Square Footage _ Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces — -• Fill: �,.._ _.. _...... -. __..w.,.. (volume & Location) A. Has a Special Permit /Variance /F nding _ver been issued for /on the site? NO 0 DONT KN• 0 YES 0 IF YES, date issued:° IF YES: Was the permit recsrded at the Registry Deeds? NO 0 •ONT KNOW 0 YES 0 IF YES: enter :•ok Pag: and /or Document # r .___ w••,... _ -.. B. Does the site cont. n a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a r- ermit been or need to be obtained from the onservation Commission? Needs to be obtained ( Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the • operty ? 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 o 's 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. rlrnent use-911- Depa City of N o rthampton Stat o f Permit , €3ullding Department Du Cut/D ve P�rmr 212 Main Street �Se e re rlSe� t t� 'A uasiabtttty ��, � � Room 100 Wa# a Av at l a rlr s ��� °'1� — 2 _ 0( b North "ampton, MA 01060 TWO Se ts al s Plans phone 41 587 - 240 Fax 413- 587 -1272 Platfite Plans „� si Otlerpe 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 7 Map Lot Unit i ti l vie; J i Z? L ® `0 6 Zone Overlay District /� EIm St District CB District SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT - ' 2.1 Owner of Record: C� - G, .�d/rCl�alG i III -4 ' / • tea.. lea. •:u/r.:. i /�I� ►.' °_i,i %� / /1 ,> Name (Print) Current Mai ing : ress it ���i G9 T ►7. \ i/i ,co. , !i_ ���i %ice ./ . elephone y Signature , 6 — (��� ` 2.2 Authorized Agent m ar bi r€ 6. � S Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Est Estimated Cost (Dollars) to be Official Use Only completed by permit applica 1. Building (a) Building Permit Fee 2. Electrical (b) im T o f _— 3. Plumbing � Construction ated from Cost {6) Building'Permi t Fee 4. Mechanical (HVAC) 2_0,60 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) CheckNumber 09 o� This Section For Official Use Only Date Building Permit Number: Issued' Signature: Building Commissioner /Inspector of Buildings Date i File # BP- 2009 -0803 APPLICANT /CONTACT PERSON SHADDUCK WILLIAM S JR ADDRESS/PHONE FLORENCE PROPERTY LOCA.00N,UST MAP 234 PA 3II Q31 901 ZONE. °B(1,Q411 THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid j $'j1° — Typeof Construction: DEMOLISH DETACHED GARAGE New Construction 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 INFORMATION 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.