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29-118 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 regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footines (before backfilf, sonotube holes (before pour), a roush building inspection (before work is . . 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 1, 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 I .. • S . 7 • . •• • ' . The Commonwealth optassachusetts Department of Indust Accidents Office of Ini e AI , 7 -„ 600 Friashington Street : =,..- .." ■ -.--1v-_- ,.‹, Boston, MA 02111 • • • , . www.mass.govidia . . .Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LegiblV • V*" I . r Name (Busiacsi/Organiiation/Individual) . / ii . - , id CtiCt"4;4-itii Celeic:{ kvi rr' I 41.1 ‘...01•1•.) Tiet/k b /0 L 5t0„--i,i (e . .-,. .-..•.- • - Address: 7 City/State/Zip: 1117 Mfg ■ • nag Phone.#: q13.-- 7,Pi—oc9s . . , Are you an employer? Check the appropriatebox: . • . •Type of project (required): / 1. 0 I am a employer with 4.. 0 1 am a general contractor and 1 • pot 6. L,,,,j New coisiruction employees (full and/or part-time).* have hired the sub-contractors listed the:attached sheet: 7. 0 R.emodeling /MI 1 am a tole proprietor or partner- • ship ondhave ii.o. employees These sub-contractors have. .8. 0 Deinolition . • • working for me in •any capaCit3' r. employees, and have workers'. : , .. ...., - • . _ • • • 9: 0 thkildtt.g.a.chtziki [No warkgs". comp. insurance required.] - . . 5. 0 We are a coxpyration and its 10.(1•Electrical repairs or additions • • . . - 3. 0 I am a homeowner doing all work officers haVeExerCiserI their . 11.0 Pluiiibing repairs or additiOns T myself [No workers' corop. • . right Of exemption per MGL 12.0f repairs . • insurance required.] t • . p. 152, §1(4), and we have no • . . . - 8 ' , 4 -1. 7 eimloyees. [No workers' - :. . • ' • -=t•s • - • . - comp. insurance reqUited.j. . : • . . . . • *My applicant-that checks box Olmust also fill out the section below showing their competutation policy information:. • ' ..f . t Homeowneri who submit this affidavit intrtating they are doing an work and then hire outside contractors must submit anew affidavit indicating such. . *Contractors that check this box must attached an additional shed showing the name of the sub ;contractors and State villether or notthose arddes have . • emplOyees. .1f the sub-contractorsIntie employees; they must providetheir woricers! comp. policy number. , : • , . • . *,. . . ' • • • I' am an employer that is Pioviding workers' 'compensation insurance for my einpleyees. 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 deg:Fallon page (showing the policy number antkeitpirn.tion date). Failure to secure coverage as reqUittid 'Wider'. $eetifitIr25A"'OfMGL 152 Cali lead to the 4os:tiro:I of iiiiiniritil penalties of a fine up to 51,500.00 and/or one-year . imprisonme4 as well as civil penalties in the form of a STOP WOBIC-OADER and a fine of up to 5250.00 a day against the yiolatOr. Be advised That a copy of tins statement may be forwarded to ilie-Ciirir . -... Eiv - • - Min* bfmL__ the Jim: "e•iiitili e ezc d 70rii1,... under the pititii-inid pe.naliiii ofieljniithai the bifinnatiOnprinidid , , Mte2' ,. _andiarreei.` ) - , • • . ..s.„4! , l e : ••." .........0 ---- -- - • • - - - ' - • : : • • • k ie - 75 i . • 4 • - - C1 , , . • ' .■....,i • : / 3 — 1' ) f • ' • , : • • - , , . . • - Official use only. DO not write in this azea, to be completed by city Or town officiaL • . • City or Town: • PermWLicense # ' ... _. Issuing Authority (circle one): :1. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical inspector 5. Plumbing Inspector 6. Other . • • f- • • • , . Contact Person: Phone #: • • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Su f - Not Applicable ❑ Name of License Holder : / 7(X c14em )9f /I1 9 f c! r / 4102 License Number O 6 rte°a erTJdk r 7/ 11/ Addres Expir ion�"°'ate // 3- 1P1 7e S nature Telephone '�"°, ' L } q �,.? £ N $.1 ecdsteeipd.Ni t io i M:C rrt lit . s,� ,. , Not Applicable ❑ ('//vj CDYiS i 61,7 5 ev'v /SO ?C.? Company Name Registra ion Number Address p� Expi do ate _ Auart)cieht MA- 0100/ Telephone ri -7,A Nit SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(61) 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 U No titt pia �itll( " :r�) 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 buildine 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [e Brief Description of Proposed /f FIT- Work: Z )zal C! &'J 4 a d , ./'T 2 Q , FIT- i rrom PYl Alteration of existing bedroom Yes X No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement x` Yes No Plans Attached Roll - Sheet 6 ] , o�St >`It�rl �d toy`. x ist tilq'ho , s hti dl'i'Iplete t he fot]4WIhq: a. Use of building : One Family ter Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? Nd d. Proposed Square footage of new construction. Dimensions e. Number of stories? s f. Method of heating? ;,?; - C;f f ° J ,; ' Fireplaces or Woodstoves /1/ C 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 7 I, _i Ki , as Owner of the subject property ) / hereby authorize [ rJIX C'"i A-1 (4e r- � C CO rJ fir✓e.1 ' to a y b n all matters relative to work authorized by this building permit application. V ` �� � ley Si re o ner Date I d1 C + 6f'i1' , as Owner /Authorized Agent hereby declare that the s atements 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. Pri • ame / Sigma of Owner /Agent 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 Ems-' 0 6 tq:/ (..' i g 1 +, -, N.u. - ._ .. j _ .�. X { 7 �, ? 5—r, "`tie { ( __ 1 Frontage t� _ _. / Setbacks Front = = i 3 Side L: r _-_! R:L.._.._._._i L:._- J R:� _.-, ' ,-..._ _ _ � Rear L.__._.i �--_ ; _ 4 Building Height i_ ._._ Sti`� i ,,. . Bldg. Square Footage 111. 1� 1% 1 1 1 1 I Open Space Footage % �� (Lot area minus bldg & paved 4 _ [ ____1 L____...� [] L t _u_ . e Parking) . 1 # of Parking Spaces -... _ Fill: 1 �� (volume & Location) -- 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 0 DONT KNOW 0 YES f tt IF YES: enter Book ( Pagej ; and /or Document # i B. Does the site contain a brook, body of water or wetlands? NO 10 DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained O , Date Issued: C. Do any signs exist on the property? YES Q NO C. IF YES, describe size, type and location: 1 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: ry i 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 o b IF YES, then a Northampton Storm Water Management Permit from the DPW is required. / ^ x ,,, 'AC,,.. , ¢ +� ' °1, y x v . 4' i 0 - . . . P mo d+' 4t n t , n City of Northampton `.' " t v ' ` u �p ' B g Department ra %. $ ;g��� ., .t> . , ` ) A a 12 , ain Street t �1 `t .. rt + r ays \ �� � �� � � �.i t�� ��� .\''N ,; yS \ R. • m 100 �1 , 0 , `, o`, ,, fi F +i.‘1,,. . ' mpton, MA 0146f) t _ .,� ' ph f3 -587 -1240 Fax 413 - 587 -1272 A 7 i APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: / 22 t2 i / et) 1. `` Map Lot Unit / rorrtl(f2.- M j Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT -,= 2.1 Owner of Record: �� �., _- - - A I! s . .r t7 0i)" <4 Fe c 65 Ct ,1 ✓ro _ ic,r 1ll 4, /c N{ll Name (P ) Current Mailing Address: , - y ip -704 7 - KC/0% .-- Telephone ' 22 Authorized Agent: / ,� /' �'} / ,° d l , / ?af�iber°�h / r c �r � tQlr at7K �/f' £thci.�''1 Name (P t) �--- Current Mailing Address: / Sig pre Telephone SECTION 3 ESTIMATED CONSTRICTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of _ Construction from (6) 3. Plumbing ,i / j Building Permit Fee 4. Mechanical (HVAC) / V// 5. Fire Protection /t � i 9 6. Total= (1 + 2 +3 +4 +5) © /,3 Check Number 73 - 7 ------— This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /inspector of Buildings Date n e File # BP- 2010 -1165 APPLICANT /CONTACT PERSON TODD CHAMBERLIN ADDRESS/PHONE 12 GREAT BROOK DR SOUTHWICK (413) 789 -0098 PROPERTY LOCATION 82 FOREST GLEN DR MAP 29 PARCEL 118 001 ZONE URA(100) //WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out r � Fee Paid Typeof Construction: INSTALL BULKHEAD & FINISH BASEMENT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 93442 _ 3 sets of Plans / Plot Plan MUST 11 AVE W tR.EO Sevuic & /co DET C1l(L 1rJ BASEMfN i THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: L"pproved 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 j?,t) Signature of Building 0 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. k BP- 2010 -1165 GIS #: COMMONWEALTH OF MASSACHUSETTS � �., ' : , E CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2010 -1165 Project # JS- 2010- 001700 Est. Cost: $6202.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: TODD CHAMBERLIN 93442 Lot Size(sq. ft.): 11935.44 Owner: BIGDA IAN Zoning: URA(100) //WSP II Applicant: TODD CHAMBERLIN AT: 82 FOREST GLEN DR Applicant Address: Phone: Insurance: 12 GREAT BROOK DR (413) 789 -0098 SOUTHW ICKMA01077 ISSUED ON: 6/22/2 01 0 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL BULKHEAD & FINISH BASEMENT - MUST HAVE WIRED SMOKE /CO DET IN 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 6/22/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo e f--0 1 0 , ..,).(zta v t k eQc ..J.-... 1 1 I 0 L , , . , , , , . ' - , . , .. , , . , . , ,.. 1 E I z ti 1 Prb C301klieg() .k* 1 . (ij • f V im {C ' I ( 1 I bl oak . )Uvta4+�or -) , 1 t I 1 , ( _._. 1 - ---A TIYI x ___ __ i --------_- -, - , , ! ! it 1 i ), 1 i____ / 1 ! 1 : , 1 1 1 1 1 ! I I ,,,..4 , 1 , i 1 1 , 1 1 i . t , i 1 0 ,(-2p0Pri I I fs: q9 P EN -. 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