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29-417 (2) ;. a � {f ii _. a f .. {f I i 4 _. :� _ : 4 I� Aw- NVIAJ r)Cole, 4t 3'. O Lity of Warthaniptan $ � �1'riassRCf�usetfs � ' - DEPARTMENT OF BUILDIJ\'G INSPECTIONS /= INSPECTOR 212 Main Street • Municipal Building Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sup,-': - sor. T he 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 any 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/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 cap 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 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 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 { A The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibly Name(Business/Organization/Individual): Cm -� Address: City/State/Zip: �t_(,,/ Phone.#: �l gL,SZ Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. F_� I am a general contractor and I �iployees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.[Er I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. 'Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp. insurance. ❑ required.] 5. F-1 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LF0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof rep��airss�� insurance required.]t c. 152, §1(4),and we have no 13. Other �%t � � employees. [No workers' I I I comp.insurance required.] *Any app t�t`can a c ec ox must also out a 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 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 file 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 Invesdeations of the DIA for insurance coverage verification. I do hereby certify under the Dains and penalties of perjury that the information provided above is true and correct Si ature: l �7 Date: Phone#: d45 Z 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: ` �i� cl-V License Number Address Expiration Date Signature Telephone x" Not Applicable ❑ 9=Redisfe ed dome lmprovek C-6n ractor•xk a, . ,,, w ... r PP Company Name Registration Number -71 AW41 Address ��� Gj�j�^� Expiration on Date Telephone L:E�(J�!`<� G— 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 bulldi g permit. Signed Affidavit Attached Y'es....... No...... ^u Homes© i1er Exei[ript>lan 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-vear 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 t - t ` 4 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑] Addition ❑ Replacement Wwows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0) Decks [E:J Siding j Other jC] Brief Des _ of Pr po_ed Work: � LA-#"-- ©P all" f!La r so- *)W4 Alteration of existing bedroom Yes_ �No - Adding new bedroom Yes tl No � Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a Ifi`New�fioUse-=and.oAradditian.to=ezisting hoiis narcomplefe theafoilo�ivfng: 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 o. s cons ruc ion wi - 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 FOWBUILDING PERMIT as Owner of the subject property �yy� hereby authorize ���%'„n to act on m ehalf, in all matte relative to work authorized by this building permit application. Signature of Owner D to 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 u der the p 'ns and penalties of perjury. Print Name Signature of Owner/A er- D e 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 Frontage Setbacks Front Side Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Spegiog Perm it/Varia nce/Fi nding ever been issued for/on the site? ox IF YES, date issued:; IF YES: Was the permit recorded at the Registry ofDeeds? �� VV NO �� DON7KNO YES IF YES: enter Book | Page' and/or Document#) / �� �� B. Does the site contain u brook, body nf water orwetlands? NO �~��� DON7KNOVV �_� YES �_� IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained v~~\ 0b�oioed v=� Oats Issued: �~� x^� ' � � C. Du any signs exist on the prope� �� ��(y? YES v�� NO , IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES �~� NO 0~1 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading .orfiUing)over 1ooeor��po�nfa common p�n ��will d�tu�mm,1 ��? YES NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Depar�neftCe City of Northampton Sttu Building Department Zurr w� r -- -- ,212 Main Street \`y'' evus :ep a rty k �1 Room 100 _. _�- -Northampton, MA 01060 etsfSucfcl �ns 111 9 pine 413-687-1240 Fax 413-587-1272 �l�e� x ��UU�� OtherpeGfy t_ 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: n Unit Zone Overlay D!stict E6't District CB Distract SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record:^ ,,,C j Name(Print) Curr�t,Maili d re (J1©6 Z— Telephone Signature 2.2 Authorize Agent: Name(Print) Current Mailing Address: /� – 61�'7-6 Signature L Telephone SECTION 3=ESTIMATED'CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building / (a)Building Permit Fee f � 2. Electrical (b)Estimated Total Cost_of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Offic 51 Use Onl" Date Building Permit Number Issued: Signature: Building Commissioner/Inspectorof Buildings Date File#BI'-2007-1237 APPLICANT/CONTACT PERSON ROBERT SPELMAN ADDRESS/PHONE 71 NASH HILL RD WILLIAMSBURG (413)268-9452 PROPERTY LOCATION 88 BROOKWOOD DR MAP 29 PARCEL 417 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildine Permit Filled out Fee Paid Typeof Construction: REBUILD SIDE WALL OF ENTRY/MUDROOM&STAIR New Construction Nan Rtn,cairal interior renovations Addition to Existing Accesso,y Structure Building Plans Included: Oven Statement or License 082172 3 s-ts of Plans/Plot Plan THE F LI.UWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN RIIA'i'iON PRESENTED: Al)pi o\c,l Additional permits required(see below) 1) ING BOARD PERMIT REQUIRED UNDER:§ li.t,,!nr­uiate Project: Site Plan AND/OR Special Permit With Site Plan i\4ajor Project: Site Plan AND/OR Special Permit With Site Plan G :;i n G BOARD PERMIT REQUIRED UNDER: § Fudim, Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Olio 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 Pcrnut from E treet Commi n Signature !,i3i:ilding Offrcia Date Note:Is,u:; ,.c of a '/_owing permit does not relieve a applicant's burden to comply with all zoning requirerncwts :uid obtain all required permits from Board of Health,Conservation Commission,Department of publi: N,- -I,s :um other applicable permit granting authorities. *Variarcc.> rc granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & I:cvelopinent for more information. -'$g BRO()KW(30D BP-2007-1237 GIS#: COMMONWEALTH OF MASSACHUSETTS Mawffid k:29-417 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-2007-1237 Project# JS-2007-001968 Est. Cost: $1500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT SPELMAN 082172 Lot Size(sq. ft.): 12850.20 Owner: MAMMARELLA JAMES J&MARY P FO Zoning:URA Applicant. ROBERT SPELMAN AT. 88 BROOKWOOD DR Applicant Address: Phone: Insurance: 71 NASH HILL RD (413) 268-9452 W ILLIAMSBURGMA01096 ISSUED ON.612012007 0:00:00 TO PERFORM THE FOLLOWING WORK.-REBUILD SIDE WALL OF ENTRY/MUDROOM & STAIR 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 6/20/2007 0:00:00 $50.00123373 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo