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29-033 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 w ch he/she resides or intends to be, a one or two, amily dwelling, attached or deta ed structures accessory to such use and/or f. m structures. A person who constructs more han one home in a two -year period shall of be considered a home owner." The building department for the • 'ty of Northampton wants per: on(s) who seek to use the home owner exemption, to act their own construction s . pervisor, to be aware that by doing so you become responsible or compliance wit ' tate building codes and . s 1 • - '1 . - . • r- •i. ' es that the bu' a in. de. artment be called to inspect work at various stages, which inc • e foundaf , n /footings (before backfill), sonotube holes (before pour), a rough bui ing in . ection (before work is concealed), insulation inspection (if require • d a final building inspection. The building department requires these inspections ■ - fore the work is concealed, failure to secure these inspections can result in failur to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to per orm work electrical, plumbing & gas) the homeowner will be responsible to make ure that the t Ides hired secure their proper - -- — — permits- in -conjunction to- • - • • ' • • • - ••• ' issued, an that they get their required inspections. Failure of the individu. trades to secure. the • ermits and inspections as required can DELAY the project u it such time as the pro. -r permits and inspections are made I, un. erstand the above. (Home owner /resident's ignature requesting exemption) I will call to schedule all re• aired building inspections necessary for the`building permit issued to me. T_ -_ Date Address of work location • The Commonwealth of Massachusetts Department of Industrial Accidents 1 _;v 1. . f Office of Investigations +. --4 1= 5 _ _ 600 Washington Street _ � ;f:r= 1 Boston, MA 02111 www.massgov /dia • -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): (V\( b M Address: 7 C- S I C1 Y. -�1 L. c� / 1J 1 t? ,l�✓ - ; �" City /State/Zip: (V»O,) l 1 U1 Phone. #: C./ / ? --2 c]( Are ou an employer? Check the appropriate box: •Type of project (required): / 1.I am a e lo..er with 4.. 0 I am a general contractor and I mP Y 6. 0 New construction employees (full and/or part-time).* have hired the sub - contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship. iM have no employees These sub - contractors have. 8. 'Deao',i -- ,ion working for me in any employees and have workers' Y ca P act ty. 9 0 Building addition [No workers' comp. insurance comp.- insurance- $. required] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I ama-homeowner_ doing --a verk- --- _._ -__2 c_es,have 1-1_ ❑ 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' 13.0 Other comp. insurance required. =Any applicant that checks box #_I 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 roust submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the nay 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 providin workers' compensation insurance for my employees .Below Ls the policy and job site information. J � p � . Insurance Company Name: it" 1"_ � � i�st Policy # or Self-ins. Lic. #: O w , Expiration Date: ✓ ^ Job Site Address: ` 1ci(J City/State/Zip: Y 0f `'' V 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 MGT, c. 152 can lead to the imposition of criminal penalties of a fine up to $1, 500.00 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. Ile 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 u der the p ' 4 ; and penalties of perjury that the information pr.ovided_above is true and t correc _. ������� • ate• �/ O Si. .. tore: PIi'r�� !� — Phone #: cd() _ ; . ?U O use only. Do not wide in this area, to by city or town offIciaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical II • ector 5. Plumbing Ins • ector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : W (LL L f" ^ 5 WCE ►\I t "1 /03401 License Number L (AIN1, w „ 0I0 Address Expiration Date Signature Telephone 9k.Reaistered Home lmtitowemertt Cantrat ai , .._m. w Not Applicable ❑ M. ti n wE r CO S'6 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 ❑ 4:4 R ey it rnrt -- O The_current_exemp n 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 s ctures accessory to such use and/ or farm structures. A person who constructs mdre,than one home in a two period shall not be considered a homeowner. Such "homeowner" shall submit to the Buildin • • fficial, on a fo ceptable to the Building Official, that he /she shall be responsible for all such work performed under t I uildin • s ermit. As acting Construction Supervisor your presence on the site will be required from time to time, during and upon completion of the work for which this permit is issue. Also be advised that with reference'to Chapter 1 Workers' Comp ation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in D- - of the Massachusetts Gener. aws Annotated, you may be liable for person(s) you hire to perform work for you .- . er this permit. The undersigned "homeg. -r' certifies and assumes responsibility for compliance 'th the State Building Code, City of • o amp On *to inances,` a e • i . + -. .- ✓ - . . al- Laws- Annotated. Homeowner Signature 1 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) -Ej Roofing ❑ Or Doors E] Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [E] Siding [D] Other [0] Brief Description of Proposed Work: WAR f p i a (f t o f s ` A 6 I " } R fv) i f W V Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative .Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa iftle*Ifailikiiittati ilOtigthillilliagifii -faild eki : 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 • _ - • e of new construction. -° Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Abb. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of w= ands? Yes No. 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, I>O.v, - - Sc- kA -e t Q V property here. authori e 1 as Owner of the subject J � r , AN se._... IAA \�, V4 � ' ""Z_" to a on my b. alf, in all matters rel -tive to work�horized by this building permit application. ho _ C _ A /iv Signs ure of Owne — " I. "' . 111r Date l r I, !°" I C S�✓eetl e�` , as Owner /Authorized Agent hereby declare that the staterrfents and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed and r the pains and penalties of perjury. Print Name 4 (l StLevie w ) ).---=_V___710 Signature of Owner /Agent Date . •i 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 ' t .. Setbacks Front _ , Side L:' J , R. z L I R: . _. . 1 1 H t ._�. Rear _...___- , Building Height ' ...... Bldg. Square Footage '" ) ? % C "' Open Space Footage (Lot area minus bldg & paved •;................i parking) # of Parking Spaces --- --w- -i - _.._. Fill: [ — �.. (volume & Location) .— ,, M l -- -- - -- : 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: IF YES: Was the permit "recorded at the Registry of Deeds? NO Q DONT KNOW Q YES illo , IF YES: enter Book ' 1 Page - I and /or Document # mw __ B. Does the site contain a brook, body o water or wetlan• ? NO Q DONT KNOW Q YES Q IF YES, has a permit been or need to be •btaine• rom the Conservation Commission? Needs to be obtained Obtai d Q , Date Issued: C. Do any signs exist on the property? Y. 0 NO Q IF YES, describe size, type • • . location: ` D: – Are there any proposes'ehanges o or a itions o sig ns ntenice for the property ? YES 0 NO Q 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 Q NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. . ,- - i , X 1 0 City of Northampton l - n a� tea. . Building Department i � � 1, 212 Main Street - �' AY ,:�t, Room 100 -�l � , . t '�Iorthampton, MA 01060 5 I phone 413 - 587 - '124,0 Fax 413 - 587 -1272 tom 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 32... eta ►iCF, 2 KtQ01-tS Map Lot Unit F (,C� irC • - ,) 1 c - o.Z Q / Katie Overlay District EfmSt District _ CB Distr►ct SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: \\ L L _ _.. v _ _ iCQN «eyt• S�(, ��:�1- 32_ p i C. .v�v((S I F( -(,t. (1 eI ©6it_ .... l Name (rnt) r Current Mailing Address: 1 i / Telephone - Signat 2.2 Authorized Accent: q c ��� ...< 6 11 �elme 7 Name (Print) / Current Mailing Address: (.'l' ,fi rvidtt.r, i(7 ? �36- Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 41S-00 (a) Building' Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4' ss- , 0 ' ¶ E e . S5, 0c -- D 4. Mechanical (HVAC) 5. Fire Protection 5 0 . Od — STv 6. Total = (1 + 2 + 3 + 4 + 5) Check Number '(i ( 6S2 1'13 16 v 0 This Section Fo O Permit Number: Irate Building Issued: . /r 2 Signature: Buil ding Commissioner /Inspector of Buildings Date File # BP- 2010 -0707 APPLICANT /CONTACT PERSON MR HOME ADDRESS/PHONE 74 CISLAK DR LUDLOW (413) 222 -5368 PROPERTY LOCATION 32 PIONEER KNLS MAP 29 PARCEL 033 001 ZONE URA(100) //WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ¢ //�� _ Fee Paid /(� Typeof Construction:_REMOVE WALL & WATERPROOF BASEMENT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 103401 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: 1/ 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 O - S l Signature of Building Of icial 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. 32 PIONEER KNLS BP- 2010 -0707 GIS #: COMMONWEALTH OF MASSACHUSETTS - . :BIc k :-29 - 033 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 -0707 Project # JS- 2010- 001052 Est. Cost: $7500.00 Fee: $160.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MR HOME 103401 Lot Size(sq. ft.): 11979.00 Owner: SCHNEIDER DAVID & HITOMI Zoning: URA(100) //WSP Applicant: MR HOME AT: 32 PIONEER KNLS Applicant Address: Phone: Insurance: 74 CISLAK DR (413) 222 -5368 WC LUDLOWMA01056 ISSUED ON :2/5/2010 0 :00 :00 TO PERFORM THE FOLLOWING WORK: REMOVE WALL & WATERPROOF BASEMENT 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 2/5/2010 0:00:00 $160.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo