The URL can be used to link to this page

35-245 (4) ¢St1AMA�. Lity of Nort4alliptall z z �' � �1A35AC�l18Ctt9 s* DEPARTMENT OF BUILDING INSPECTIONS /= INSPECTOR 212 Main Street • Municipal Building , O M y Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to act as iris/her construction sups;: . :-,or. 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 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 rouzh 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 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, a4l 1,1,611 understand the above. (H(6Wowner/resident's signatu rep sting ex mption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location dl , 6 . The Commonwealth of3llassachusetts 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 Legibly Name(Business/Organization/Individual): J ry.�,J V y eSTC 1 Address: ? LAD�y�n�ar Lgti D 2eN e� /1�iq City/State/Zip: Tl©lZeAj(_e M6 0/66Z Phone.#: V S - - 29/7 F 2.0you an employer?Check the appropriate box: Type of project(required): I am a employer with 4. [] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. [�New construction I am a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' insurance.$ 9. ❑Building addition [No workers' comp.insurance comp. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12. insurance repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *7Yn a a c ec ox must a o out a secnon a ow s owtn etr workers'co y pp g mpensation 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 fire 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 Investigations of the DIA for insurance coverage verification. I 'hereby ce ' under the pains and penalties of perjury that the information provided above is true and correct. Si ature: // Date: 7-12 Phone#: 7�� - 32en? 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: License Number Address Expiration Date Signature Telephone 9 Registeretl Nom`e_CmprovementContracfor ate * $t ._, a 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...... ❑ 11.. Home.. } ner:Exeii�ih 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 Gable 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 ,plorthampton 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 ❑ r1�1 Or Doors F-1 Accessory Bldg. 25 Demolition ❑ New Signs [0] Decks Siding[0] Other[0] Brief Description of Proposed FAA 2�>P� / ' Work: l!)/X / r � Alteration of existing bedroom Yes No Adding new-bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa_lfiNew hawse anct or.-adCl�ttoii�=to existlng tatlsrnct-co`rriplete fhe ti OWfrid d 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 construction within 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 as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 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 ypder the pains and penalties of perjury. _ J Cyr w e ST�Pti Prin me �.�. 1 7 S~ Sign ur of Owner/Agent Datel . � . . , ' ^ 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 A�r Rear A0 Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Special Perm it/Vari nce/Findi been issued for/on the site? IF YES: Was the permit recorded ut the Registry ufDeeds? �� NO �� DON7KNOVV YES IF YES: enter Book / Page. ! and/or Dnnument# ------------ --------- -------'---- 10% �� B. Does the site contain a brook, body of water orwetlands? NO ��, DON7KNOVV �.� YES ��/ IF YES, has a permit been or need Ln be obtained from the Conservation Commission? Needs tobeobtained _��~� Obtained �v_�� Dats |ssued�' / | � ' � �� C. Do any signs exist un the pnoper� 0%� YES �~/ NO Vy � ! IF YES, describe size, type and location: , D. Are there any proposed changes to or additions of signs intended for the property? YES �~� NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre orini1 part ofa common plan that will disturb over 1 acne? YEG � ) NO �� n� IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Qepatlmentuseonly ' it b Northampton Status b J 6 tt 4. -'"BuiPd)n Department �GurCaDrr�eurPemut `- . 21211 In Street S�vuerSepticAaabititsr ; 000m 100 ltArratfabiltty Northar► pton, MA 01060 ToSeteofStrirtcrraFPCans phone 1351240 ax 413-587-1272 PloffSite Plans _ r K A�PLICA�'PdNjOL�STRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING F� SECTION 1 -SITE,INFORMATION This section to be completed by office. 1.1 Property Address: tAOL A 1v E. Map Lot Unit Z'one Overlay District Elin St,District CB Distrrct SECTION"2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _ o0 W� Ted-tj ep,11 Per- r r1r JZ L A0461.'t)Dcr LA &X-, rloxpAv- e-, /h.A Name(Print) Curr t ling re a6� '1". -- M + 3gI7 Telephone Si ure 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 completed by ermit applicant 1. Building U� 6 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) / 5. Fire Protection 6. Total=0 +2+3+4+5) oo Check Number This Section For Official Use Only Date Building;Permit Number. Issued: Signature: Building Commissioner/Inspector of Buildings Date .� «••� t � r '�"�.� f A a I A/ ' �""� I O 1 +^' wXw G w OOW r~L A �2er c File#BP-2008-0090 APPLICANT/CONTACT PERSON WESTERN JON W&JENIFER URFF ADDRESS/PHONE 27 LADYSLIPPER LN FLORENCE (413)586-3917 Q PROPERTY LOCATION 27 LADYSLIPPER LANE MAP 35 PARCEL 245 001 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin14 Permit Filled out Fee Paid T_ypeof Construction: ERECT 10 X 14 SHED New Construction Non Structural interior renovations Addition to Existing Accessory Structure BuildinIZ Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan i THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION PRESENTED: THE 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 ssion Signature of Building Official Date 2 r LOb� 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. BP-2008-0090 GIs#: COMMONWEALTH OF MASSACHUSETTS 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-2008-0090 Project# JS-2008-000136 Est. Cost: $1700.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 38202.12 Owner: WESTERN JON W&JENIFER URFF Zoning: SR Applicant: WESTERN JON W & JENIFER URFF AT. 27 LADYSLIPPER LANE Applicant Address: Phone: Insurance: 27 LADYSLIPPER LN (413) 586-3917 (� FLORENCEMA01062 ISSUED ON.713012007 0:00:00 TO PERFORM THE FOLLOWING WORK:ERECT 10 X 14 SHED 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: FeeTvpe: Date Paid: Amount: Building 7/30/2007 0:00:00 $25.001144 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo