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32A-235 (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 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 pi cess_re_quires 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 - - - - -- ---- permits-i-n- conjunction.,to_the building.pprmir 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 ��,y/�. understand the above. : ome owner /r • s ` p t's sig . ture requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. —mate '7— Address of work location POrner r ✓� --�sZ MA re, ) (3 ( ) (- The Commonwealth of Massachusetts Department of Industrial Accidents .� r - 1 Office of lnvesti , ations • ®L— a i. _ 600 Washin Street 0 = I Boston, MA 02111 . _ www.rtzass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,.�^' Please Print Legibly Name ( Business /Organization/Individual): e.,J "l 1 5' 6,4-44p,(4 . Address: ,a - 3 of ( b Cl City / State / Zip: 'Jo 1 -r4r r44 p fsJ, 4 #'r Phone.#: , .6 - 6"Ze — `7 3 `7 e Are you an employer? Check the appropriate box: •Type of project (required): J,_ 1. I am a employer with 4.. 0 I am a general contractor and I 6. 9 New construction employees (full and/or part - time).* have hired the sub - contractors 2 I am a sole proprietor or partner- listed on the attached sheet 7. Remodelin Q ship and. have. no en loyees These sub - contractors have 8. 9 Deaol on ld for me in an capacity. employees and have workers' working Y P ty $ 9. 9 Building addition [No workers' comp. insurance comp. rnstrranr e. required:] 5. 0 We are a corporation and its 10.� Electrical repairs or additions 3. El I am-a- homeowner- doing -allwork - o c _u$ °c xer_cised their 1_- 1. Elf?l bingrepairs or additions myself [No workers' comp. right of exemption per MGL 12.9 Roof repairs insurance required] t c. 152,§1(4), and we have no employees. [No workers' 13Other Rp4d /14 comp. insurance required.] 1..}r po ¶ S "Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infomotion_ 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 ariditioaal sheet showing the name of the sub - contractors and state whether ar 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 ormation. :v17/4 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 up to $1 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. Ige advised that a copy of this statement may be forwarded to the Office of Investieations of the DIA for insurance covera.ae verification. _ I do hereby certify under the pains and penalties of perjury that the information provided! above Istrue and_corr-ect .._ _ Signature: 7 / "P1��!.: i Date: • Phone #: g' - `7 3 7e .. _ Ofcial use only. Do not write in this area, tube completed by city or town offieiaL City or Town: Per-mit/License #____ Issuing Authority (circle one): I: 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 : - - -- - - - - - -- - L- iccnaeilti — —, Address Expiration Date Signature Telephone 9...Registered; Home' lmprovementContractor Not Applicable Company Name Registration Number Address Expiration Date Telephone .. .......................... 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 ❑ No ❑ ...- HomeOwuerE;, l'Ation 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" cert • -s and assumes responsibility for compliance with the State Building Code, City of _ ._ _ .. • • .� •- �,,,.• _ . -: , -` � . _ - . -- -tts- General -Laws- Annotated. dt ampton • r finance , a e - • • Homeowner Sign / a T�.r4 l i SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Ur Uoors D Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding [D] Other Brief Description of Proposed eEp �' . 1-Rek,T- pn pdy f ' S (c, gr ps Work: Alteration of existing bedroom Yes X No Adding new bedroom Yes X_ No Attached Narrative Renovating unfinished basement Yes Xs No Plans Attached Roll - Sheet 6a_ i €.Nev+r " hottse=ancf i additioiii6 ho sing :eomplete the foiiov ing: 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 Ta - OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT J o 1 ' l ` . , as Owner of the subject property ' /Y / L hereby authorize '1 J /(�✓4 Cs4 ✓ � 5 'iP - __ to act on m beh)f, in all matters relative to work authorized by this building permit application. •nature of Owner e ` 7 ® Date , as Owner /Authorized Agent'herebyy 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. i L . ktiST Pn'nt Name •> ature of Owner /Agent ief D to 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. _ R._ Rear Building Height Bldg. Square Footage % Open Space Footage (Lot area minus bldg & paved Nar king) # of Parking Spaces Fill: . ..._ (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 0 IF YES: enter Book r Pagel? and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 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 104 IF YES, describe size, type and location `gre there any proposed c anges to or a..itions o signs intenZed -for tthie property ? YES 0 NO • IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, gradin ex ovation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO 4 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. L City f Northampton tY Building Department Cu �bve+irryser�rtt 212 Main Street ecAvbi y �� 3 � Room 100 �;������� 60 phone 413- 587 -1240 Fax 413 - 587 -1272 Qttieectf s�. APPUCATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO" FAMILY DWELLING J SECTION 1 - SITE INFORMATION . D El, cvU` This section to be completed by office 1.1 Property Address: L_ __ 0 p©v3 Et Li - 7-Ct �Q LE Map Lot ) /Oi 7 Tl t Mop o t t Zone ' Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Curren Mailing Ad Telep ne g " re 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only com Ieted by permit applicant 1. Building 00 �Q (a) Building "Permit Fee 2. Electrical Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanicai(HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) -� =f/ li�. ' ,00 Check Number — This Section For Official 'Use Only Date Building Permit Number: Issued: / R ©7 Signature: Building Commissioner /Inspector of Buildings Date BP- 2010 -0586 GIS #: OF MASSACHUSETTS S'< ' CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: REPLACEMENT STAIRS BUILDING PERMIT Permit # BP- 2010 -0586 Project tt JS- 2010 - 000409 Est. Cost: $600.00 Fee: $0.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 28401.12 Owner: SHAFFER JUDITH K Zoning: SC(40)/URC(60)/ Applicant: iudith shaeffer AT: 20 POMEROY TERR Applicant Address: Phone: Insurance: 20 pomeroy terrace (413) 585 -5911 0 NORTHAMPTONMAO1060 ISSUED ON:12/9/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT STAIRS 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: /7 /q Building 12/9/2009 0:00:00 . 0 V 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo