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QOF- NF- F-Jrtn F- LLOF -ZC�cn F -QQwQZ F- ar a = U J www¢ Q a zzaQ 3 F-LLS ro00� roQXZ =OH¢Qwww »o = }C9 \ CL U N N W Opp J J X o Lu rp p (n }cn Qm F- F- EImwmu -LL mzzm=LLC7U 0 F-CC ( e HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 7809MR 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 " two family dwelling, attached or detached structures accessory to such use or farm structures. A person who constructs more than one home in a two -year perio shall not be considered a home owner." The building department for the City of Northampton w is person(s) who seek to use the home owner exemption, to act as their own constru 'on supervisor, to be aware that by doing so you become responsible for complianc with state building codes and regulations. The inspection process requires that building department be called to inspect work at various stages, which include fo dation/footin (before backfill sonotube holes (before our a rouLyh buildi Ly inspection (before work is concealed insulation inspection if uir and a final buildinz inspection. The building department requires these inspecti ns before the work is concealed, failure. to secure these inspections can result in f ure to obtain a certificate of occupan until the work can b !P6 d d. If the homeowner hirdes perform. work (electrical, plumbing & gas) the homeowner will be reto a sure that the trades hired secure their proper permits in conjunctio' ing permit issued, and that they get their required inspections. Failure oidual trades to secure the permits and inspections as re quired can DELAY t until such time as the proper permits and inspections are made I, understand the above. .(Home o/schedr ident's signature requesting exemption) I will call to all requir ed building inspections necessary for the building permit issued to me Date Address of work location • y - The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations ' 600 Washington Street Boston, MA 02111 m ww.mass gov /dia - Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print L - blv Name ( Business /Orgmizatiow7mdividual):. 6( Address: City /Sta&Lp: QvrVCS? .' Phone. #: 5&q - 2(UD Are you an employer?. Check the appropriate boa: T e of ro ect r . /� 1. E3 am a employer with .. 4.. E3 I am a general contractor and I employees (full and/or part-time). # have hired the sub- contractors 6. ❑ New construction 2�I am a sole proprietor or partner- listed on the-attached sheet 7. Remodeling s hip and have no emloyees These sub - contractors have. .8. (� Demolition working for me is any capacity. employees and_laye workers' > inm?ranrr #.:., .- 9• �j Butldmg °auddition [AFo workers ' eomp: in.S„ra„r -- _comp- _ -- re�ec ] 5. E We are a corpoiation and its 10 ❑ Electrical repairs or additions 3. I am a homeowner doing all work officers have 11. Plumbin xercised their g 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. insuranc requirp .1 `Any applicant 4hat checks box #1-rmst,also fin out the section below showing theirwod= -s'- compensation policy information: t Homeowners who submit this affidavit:indicating they are doing an work and then hire outside contractors must submit a new affidavit indicating such. 'Comactors that check this box must .attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub- contractozs have employees, they must their workers' comp..policy number. I am an employer that isproviding workers compensation insurance for. my employees Below is the policy and job ske information. - Insurance Company Name: . Policy # or Self-ins. Lic. #: Expiration Date: J Si te A dd re ss: City /StafzlZip: Attach a copy of the workers' - compensation policy declaration page (showing the policy number and expirati on irate). _ - Failure to secure coverage: as require under Section'25A oflvlGL c. 15Z cirri lead toe ' osition of crimuI penalties of a fine up to $1,500.00 and/or one. -year imprisonment;' as well as civil penalties m.. the form of a STOP WORK and- a fine of up to $250 00 a day against tiie violator Be advised that a copy of this statement maybe forwarded -W the Office of "Iiivestiiitious`ofthe'D for insurancecoveraze verification I do hereby certify pains and penalties of perjmy a& the information provufed_abov r�lrfcr_aridcorrect_ -- Si t¢re ate• 167 j? Phone #: Official use only. Do not write hi this area, to be completed by city or town offuial City or Town. Permit/Llcense # Issuing Authority (circle one): J. 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 0 Name of License Holder o ( ( [ 3 ( 1 8 License Number a -3-1Z- Addre Expiration Date 1 5 - 8 4 4 z too Signature Telephone SkReaistehlfnttiiirnrbielmenl `corj —MM Not Applicable 11 C aVJel/ Company Name Registration Number q - 1 Cher S—� r 2 —((;: — 1 ( Address Expiration Date Telephone w — W OD SECTION 10'- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 462, ,1 25C;(S)) 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...... ❑ P 4m Qner1� 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'_-fcheck all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [M Siding [01 Other [a Brief Description of Proposed 1`2[x' �(��C _ h © CiNS Work: -- Alteration of existing bedroom Yes No Adding new bedroom Yes Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet Se Bair lt� �c in us�a c� n�t�ee 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. D' nsions 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 1 of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of bas ion or cellar floor below finished grade k. Will ding 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 1 vQ,�.evi g as Owner of the subject property I hereby authorize to ct my behalf, in all matters r lative to work authorized by this building permit application. a lit ,Ufa IU _t -�.. Signature of Owner Date 1 O �(� P 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 r the pains and p nalties of perjury. GA 0 (avdec ,- Print W Signature of Owner /Agen Date ^ Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed �Required by Zoning Jhis column to be filled in b ,Building Department Lot Size IZ7Z Frontage Setbacks Front =Z1 Rear IL Building Height Bldg. Square Footage 010 Open Space Footage % (Lot area minus bldg & paved I parking) # of Parking Spaces A. Has a Special Permit/Vahance/ Finding ever been issued for/on the site? NO 0 DON7KNOW XD YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds NO 0 DON7 KNOW YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain abrook body NO n�� DONT�NOVV »�� YES »~� , v�f »�� �-� IF YES, has permit been or need to be obtained from the Conservation Commission? Needs tmbeobtained �~� Obtained »r~� Date ---1 �~� C. Do any signs exist on the property? YES � NO �� |F YES, describe size, type and location: | ! _______-___-_1 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, gradinexcavation, ur filling) over 1 acre orisi| part nfo common plan that will disturb over 1acre? YES�� NO��� �� �� |F YES, then o Northampton Storm Water Management Permit from the DPW is required. City N hampton OCT 2 4 2t14ildi g partment 21 Ma Street oo 100 oc of etr`°t"o , MA 01060 phone 413 - 587 -1240 Fax 413 - 587 -1272 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 .Map Lot Unit V t4 Cf f r� Zone Overlay Distr ct Elrrr St District CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record Val -eln-e- Name (Print) Current Mailing Address: ik ki�uw�n � L Telephone Signature 2.2 Authorized Agent: CJ( e u' Name (P' t) Current Mailing Address: Z (00 Signature Telephone SECTION 3 - !ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building /� ��„-�O (a) Building 'Permit Fee 2. Electrical `-T �� (0) Esbmated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= 0 +2+3+4+5) OU (� Check Number This Section For Official Use Onl Date Building Permit Number. Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0416 ' APPLICANT /CONTACT PERSON EDWIN OLANDER ADDRESS/PHONE 97 CHESTNUT ST FLORENCE (413) 584 -2100 Q PROPERTY LOCATION 21 HINCKLEY ST MAP 30B PARCEL 046 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid Typeof Construction: REPAIR PORCH New Construction _ Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 049348 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOPSMATION PRESENTED: 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 Signature of Building Official 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. 21 HINCKLEY ST BP- 2012 -0416 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Bloc 30B - 046 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 -0416 Project # JS- 2012 - 000661 Est. Cost: $4000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: EDWIN OLANDER 049348 Lot Size(sq. ft.): 21997.80 Owner: SCHUMACHER VALERIE A Zoning. URB(100)/ Applicant. EDWIN OLANDER AT: 21 HINCKLEY ST Applicant Address: Phone: Insurance: 97 CHESTNUT ST (413) 584 -2100 () FLORENCEMA01062 ISSUED ON :1012512011 0:00:00 TO PERFORM THE FOLLOWING WORK.- REPAIR PORCH 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 10/25/20110:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner