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31A-180
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"j - 3 g CV )1-1/ a il ovvt-1 - 11 (9 ry -95 a— 44v) -0 L- 4--}1' vin3" N 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, act as their owir 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 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 iermits 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 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 -.4.•' r-=.-- Department of Industrial Accidents . , ..1=rtlit..r..—.... ' Office of Investigations'. . . .....,, . — - -' MIL:....=. ,-.. i 600 Washington Street =z1g.E 4 i. , Boston, MA 02111 • !,.. www.mass.gov/dia • - Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legiblv Name pusineseorgadzationandividuaD: /e.Levi /0 F bow/0 i 'Fit/ LA-C—e__ -,.. . , .. • • Address: 140 1 , 4 09a_ g kil Li_ e.)t) . , City/State/Zip: (1, w A r i 1 44,4-- 0134-1 Phone.#: 413 --34, q - 43 3'2_ - Are you an employer? Check the appropriatebox: • . Type of project (required): • 1.0 I am a eniployer with • 4. 0 I am a general contractor and I 6. 0 - NeW construct 'cm have hired the sub-contractors • ,efiaployees (full and/or part-time). listed on thatched sheet: 7. 121.emodeling 2..ag I am a Sole proprietor or partner- ship ond have no employees These sub have -8. Q Deniolition . . . . eugiloyees andhave workers' _.: :-....... :.,.._1.1. „... -.._ __ __* • working for me in any capacity. 9 - 0 Bruilchlig n.dition [No workers' comR. insurance - cm°13-- iPil l th'..- - - K --- - -- - - ' - ' -'- ' ' ..._, requir •• : 5. 0 We are a corporation and its 10 -In Electrical repairs or additions 3. U I am a homeowner doing all work officers haVeCiethised their . 11.ErP1innbing 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.j. : . • : . *Any applicant that checks box n must also fill out the section below-showing their compensation policy informatiOn. 1. Homeownera who submit this affidavit imficating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. :Contractors that check this box mustattached an addtional sheet showing the name of the subcontractors and state witether•ornotthose.entities have . • employees. If the sub-cormaciorsliMie employeeS, they must provide their wOrkeis' comp policy number : : • : . 7 : ! . • . . , . J am an employer that is providing workers' compensation insurance for my employees. Below is the poliCyandjob site information. Insurance Company Name: . . Policy # of Self-in.S. Lic. #: • Expiration Date: - ' • . , . . Job Site Address: : .' City/State/Zip:'N0 eTifkraicriPN A44- - Attach a copy of the workers' compensation policy declaration pago(showing the policy number andexpiration date). . _ _ . • _ Failure to secure coverage as required mider SeCtiiiit 25A 152 can lead id the iinPOSitrOri of Climbing fienalties of a fine up to S1,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK-ORDER and a &.e of up to $25000 a day against the violator Be advised 'that a copy of this statement may be forwarded to the:OitCeof Iiiv O - ldie DIAfot nistirande eoviiiii verification. . _ . :•_, ,:..-........ ....-,_ -,,,,...,:.„.: , , _ ., „.• ,_.... ____ __. _ ._ ____, _ _ ., ____ _ fito heiski. t4e p , ' :An . , .. a of:pedal,' thatthe inforntationprovideilabove_andiorriact ' Sa e: " X tr irthtur i-t • , , r)-1-- -, - . 0 :- 7 ' - - -7 5 - ate: — ' It/ 2,4 I • . . . — Phone*: 4 t3 —36,c( -- x - 4 - ,#.32.... • . • • - ' • • • - • • . • . - Official are only. Do not write in this. area, to be completed by city or townOfficial City or Town: Permit/License # Issuing Authority (circle one): -- - . .1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electricalppector 5. Plumbing Inspector 6. Other . Contact Person: Phone #: • • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ I Name of License Holder : Kt V! A) bO vJN 1 E ' &.3" License Number L O IPP 1 4 . 1 N tn! 31 02] 2 1 Address 01 Expiration Da 413 "3 a - +33 2 Signatu Telephone 9; ° e we • A . m r eimeiin '� -'c q • - , 9 .... 1,7 0 f itE Not Applicable ❑ Do t4) n,1 1U c' 05 3-5 Company Name Registration Number 140 uPPi ST th e-15• )kIk ' 4LlA 24 / 2c'i z- Address 013 4-( Expiration D to C.l t-f Telephone413734 — +332. SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C 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 buildin ermit. Signed Affidavit Attached Yes No 0 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition El Replacement Windows Alteration(s) Mr Roofing ❑ Or Doors O Accessory Bldg. El Demolition El New Signs [0] Decks [C] Siding [0] Other [D] Brief Description of Prop g Work: � `tt1�G{ / J Alteration of existing bedroom Yes i/ No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes V No Plans Attached Roll - Sheet a. Use of building : One Family le 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 I, - 714 - 610k" tb t , as Owner of the subject property hereby authorize V26l1/..) Ft. 1> (3%A) to act on my behalf in all m tters relative to w rk aut orized by this building permit application. Signature of Owner 7 Date I, V /,v l' ►}7 ev .,V i F , 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 Signatu of Owner /Agent Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete In rmation Existing Proposed Required by Zoni g I This column to be fill in by Building Department E_ . Lot Size I 1 4 ; _ _, Frontage Setbacks Front f 71 j Side L .. • R.= �� L:si J R ; _ f 1 Rear l i # L Building Height ZS . _. I 1 3 Bldg. Square Footage Ziv % I i i Open Space Footage % (Lot area minus bldg & paved ,ffEll j .. { ,. parking) # of Parking Spaces 1 I i -__. Fill: 1 �w 1 u (volume & Location) ` - z L„.... A. Has a Special Permit /Variance /Finding ever 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 0 DONT KNOW YES 0 IF YES: enter Book Pag 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 0 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 property ? 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 or is it part of a common plan that will disturb over 1 acre? YES Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 0 RECEIVED , s f t - ' C of Northampton Y 5 Building Department - f �t � 1 4 , JUL 11 j 212 Main Street t f`� ** x i Room 100 a ,w= i I ® i 4 , �.`p A FGUIDING INSP ECTIq Northampton, MA 01060 J N•Mawaeo -' -- 9 '' 413 - 587 -1240 Fax 413 - 587 -1272 �' 0 3, 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 2_3 NA-54,a �-#'b ,t/6 . map Lot _ Unit N©E wIP V N : 0 I 0 (o0 zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: k f 4) 6 MA 23 wA s, i 1■31YU 16 I E Name Print) Curre t Mailing Address: SS4 q�q ..-- � Telephone Signature 2.2 Authorized Agent: 1 40 w R'Fe- S AP HI 0 eb , 1 , r.4 A) A A"( ,,1,1 A- ::% 1341 Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only _ completed by permit applicant 1. Building 4 2-21 4n c t=0 (a) Building Permit Fee 2. Electrical . Q U ( b ) Estimated Total Cost of R �" S Construction from (6) 3. Plumbing , Building Permit Fee 4. Mechanical (HVAC) 4/(a li 0 0 : v C,) 5. Fire Protection 4, I C 0 Check Number = ( + + +4 +5) .4'�l � � � ��/ 6. Total This Section For Official Use Only Date Building Permit Number: Issued: �� Signature: � f � ,r,.. . � ' ' / Building Commissioner /Inspector of Bu Date l RECEIVE 23 WASHINGTON AVE BP- 2012 -0089 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 180 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- 2012 -0089 Project # JS- 2012 - 000138 Est. Cost: $51707.00 Fee: $310.20 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KEVINF DOWNIE 46673 Lot Size(sq. ft.): 11456.28 Owner: HARDIGG THEA CATHARINE Zoning: URB(100)/ Applicant: KEVINF DOWNIE AT: 23 WASHINGTON AVE Applicant Address: Phone: Insurance: 140 UPPER BAPTIST HILL RD (413) 522 -7711 CONWAYMA01341 ISSUED ON :7/26/2011 0 :00 :00 TO PERFORM THE FOLLOWING WORK :INSTALL ATTIC INSULATION,REPAIR FOUNDATION,REMODEL 2ND FLR BATH 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 7/26/2011 0:00:00 $310.20 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner