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17A-242 4 , I 1 ‘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, 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 inspectinx piaEess 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 - - - - -- per -nits- in- conjunction_to- the_ building _permit_issued,_and_ 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. ate Address of work location ` ,\ The Commonwealth of Massachusetts __ -'-- Department of Industrial Accidents 1 =Re Office of Investigations • • iu .� 600 W ashington Street t Boston, MA 02111 .,•'' www.mass.gov /dia -Workers' Compensation Insurance davit: Builders/ Contractors /Electricians/Plumb.ers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): r � Address: �b # - r , ice City /State/Zip:.�r'f ,/�� Ji i P ho ne.: �3S '�' 7/7 Are ou an employer? Check the appropriate box: y Type of project (requited ): / 1.0 I am a mployer with 4. 0 I am a general contractor and I 6. 1,w ogees (full and /orpart- time). * have hired the sub- contractors 2. I am a sole proprietor or partner- listed on the attached sheet 7. 2Remodeling ship and have no. employees These sub - contractors have. 8. 0 Deruol on for in an aci employees and have workers' working y capacity. 9. ❑ Building addition [No workers' comp insurance comp_ insurance .t required:] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. [l I am -all wo rk _o c__enss_ ave is_ed their --1-1-- - P.lurnbing repairs or additions myself [No workers' comp. right of exemption 'per MGL 12.0 2oof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. Other CX. _ comp- insurance required,] *Any applicant that checks box #1 must also fin out the section below showing their workers' compensation policy infomtation. , 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 .artarhed 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 formation. 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 afi of up to $250.00 a day against the violator. "1$e advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverat= erification I do hereby certify under the pains and p ' ; s of pedury `that the information provided_abov _ ' , e_ indcorrect — - ..- i Si. a - tore: _//. ir..�►�®—M s . 0 Phone #: / // 3-- 71 Official use only Do not write ti this area, to be completed 5y city or town offie at City or Town: Permit/License # Issuing Authority (circle one): f. 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 : emcz /� 6 p License Number / 9 17 - 57 1/ 0/0 Address Expiration Date ///:/5 7:1-'11,23 re Tele one P 9. Registered Home l® ti ®vementContra or , ::. , r _. _'y y .s ..; .w" Not Applicable ❑ e 1 ! M .G 1/ ?9' 7 • Company me . Registration Num er / 20 / .th. 1 22 /6/ Address Expiration a e ' e ' e ? , %,/ S 10- Telephone/ .e,/ ' 53(1/7 _ _ 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 buildin "permit. Signed Affidavit Attached Yes No ❑ _ _ The_current_exemption for `homeowners" was extended to include Owner 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 1083.5.1. 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 Supervisur yuut presence on the job site will be required from time to time, during and npnn 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 __ - ---- ®o ampton • r • mances, - • . • i , ., , . - tts - General- Laws- Annotated. - Homcowner Signature i s I, , I SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement�dows Alteration(s) ❑ Roofing ❑ Or boors Accessory Bldg. Demolition ❑ New Signs [D] Decks [l Siding [1:,7.11 Other [O) 0' c' � ® ► r 01 t P N 0 e7 iS T l/ t). 4 VC' 0 19 - A4'cr ' Brief D- cription of Proposed J Work: a . . • -- -;t :. , — at _ f -, it ii.: ` r ► . a 6)/P/ Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes " ' No /� Attached Narrative Renovating unfinished basement Yes jr No Plans Attached Roll - Sheet sa ; !f Miew S ous eland ,iii a; rteon to "exist[ "nq ho . com tFie -fc�I 1 g. 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 7a - 'OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT -- : , as Owner of the subject i property � i ct hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 1, e 1 F rj TJ ,� , as Owner /Authorized Agent hereby declare hat tl a statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the ury. p in and penalties of p 7 J71/7 7 Print Name ✓' - ,./.r 1 .t r. /r $ d- - - — Signature of Own: • Date .✓ Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Proposed Required by Zoning i Ax i igte„,,,i i* This column to be filled in by ( Building Department Lot Size �_..,_ __..1.. �� �. o.. ._._. L___—_—_—___..,„..,_ , Frontage ?7 ,- Lc .-- Z 5-------,: ' � Setbacks Front Side L.. u R. ? .. L:u.. _. R •, Rear / � f ,.. Building Height i Bldg. Square Footage ,. % _` `.._.._._. Open Space Footage (Lot area minus bldg & paved t „ �_ . parking) # of Parking Spaces — -- _---° Fill: K— ; (volume & Location) _ w.__�_.„... ,.._._ ._......._. µ, ._..w_ __. ___ A. Has a Spe al Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page; i and /or Document #, B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date issued C. Do any signs exist on the property? YES 0 NO er IF YES, describe size, type and location: r ------ -- -n - - =- rm? t a�a aTrj — rri` 65753 c - arises _o or a _ 1t on5 si ns in Pn Qr ni YIiP rn rt 7 YFS 0 NO yP R -._ c or o 8 P f� y IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excav ' , or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. t. ` i kri X 40 ,P,0t 4i, City of Northampton St�ao�extti� Building Department Ctittatvay�et r 212 Main Street Sw+��itdlvatbt 3k �s Room 100* Northampton, MA 01060 ,roto phone 413 -587 -1240 Fax 413- 587 -1272 14 �'# ., °� 1 � `Spe�t�y 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: 7 2 ZiVE- Map Lot Unit 7,4,L l %V(z" d4- `Zone Overlay District ' EIm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Ofner of Record: 7 heer " l4 7- —1 Name (Print) Current Mailing Address: Telephone Signature 01030 2.2 Authorized • • ent: fir C Jr iT" 0 7 1 1(1 rn1 5 4- AA / S Name (Print) Current Mailing Address: ... .r►'.. =!� /1 /_ 33r Signature Telephone SECTI • 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building /7 C . ( 2 1 •(a) Building Permit Fee 2. Electrical / Gj • `;, (b) Estimated Total Cost of • Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) - 5. Fire Protection � C U Check Number � 6. Total 1 + 2 + 3 + 4 + 5) 2eck Number This Section For Official Use Onty Date Building Permit Number: Issued: Signature Building Commissioner /Inspector of Baitdings T Date , t . • File # BP- 2010 -0597 APPLICANT /CONTACT PERSON JEFFREY E SMITH ADDRESS/PHONE 207 NORTHWEST ST FEEDING HILLS (413) 335 -3717 PROPERTY LOCATION 72 LAKE ST MAP 17A PARCEL 242 001 ZONE URB(100j/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid 7P C4080 Typeof Construction: CONSTRUCT 12 X 25 DECK TO DET GARAGE & CONVERT GARAGE TO WORKOUT GYM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 083719 3 sets of Plans / Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: Approved 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 ��2 /el g Sig ature 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. V. ir, t BP- 2010 -0597 uis 4: 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- 2010 -0597 Project # JS- 2010- 000869 Est. Cost: $22000.00 Fee: $132.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JEFFREY E SMITH 083719 Lot Size(sq. ft.): 16160.76 Owner: LANGLAIS LINDA A Zoning URB(100)/ Applicant: JEFFREY E SMITH AT: 72 LAKE ST Applicant Address: Phone: Insurance: 207 NORTHWEST ST (413) 335 -3717 FEEDING HILLSMA01030 ISSUED ON:12/22/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT 12 X 25 DECK TO DET GARAGE & CONVERT GARAGE TO WORKOUT GYM 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 12/22/2009 0:00:00 $132.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo 72 LAKE ST BP -2 01Q 0597 Gls #: CO M MONWEA LT H OF MAS T � £ Nla :Block 17A - 242 CITY OF NOR 4'.';'-`-' .. Lot: -001 PE CONTR WITH UNREGISTERED CONTRA - Permit: Buildin DO NOT H A CC E SS T O THE GU ARAN TY • FU (MGL C.,- 1 4 2A . Categor B U Ij DING P EA S. Permit# B P - 201 -05 t 2 %. Pro j e ct t JS- 201 - 00 0869 . : 7 ' Es Cost $22000.00 . Fee $1 32.00 PE RMISSI ON IS H EREB Y G :TO: . Cons Class: Contractor Licen � t l f =` Use Group JEFFR E SMITH 08 3 719 ` ` • Lot Size( ft.): 1 6160. 7 6 O wner: LANGL LINDA A on in : rltBt l o�)/ Appl icant: JEFF E S MIT E — A T: 72 LA ST App l i c ant Ad dress: Pho ne: In nc. '�- 207 NORTH S T (4 33 -3 7 1 7 FEED' HILLSMA0 ISSUED 01V:12/22/20 0:0,,°- _, .. TO PE R FORM THE F 12 X 2 DECK T O DE` G - Est i £x & CONVERT G A RA G E TO WO RKOUT GY as ,t -y" ' ' , : POST THIS CA SO IT I VISI BLE FROM THE STREET . Inspector of Plu mbing Ins p e ctor of W irin D Building-1 nspec - Underground: Service:. Meter EI . I at .'u..,. p Footings n• : f , � � �.' Rough: Rough ,,, House l me Fo undati o Driveway Fina Final: Final: d I///° r 49 Rough Fra , K ::: r.-4 Gas: F ire Departmen Fireplace / hitnl�ey: r ' ��:sga: coil' Ins ulation: t _ 4 . -t - t � Final: Smoke: Final THIS PE RM IT M AY BE REVO BY THE CIT OF NORTHAMPTO U PO N V I O L ATION O ANY OF ITS RULES AN REGULAT � " Certificate o Occu • anc �. S - � Fee Type: Da te Pai d: Amount { Building 12122/ -2009 0:00:00 $13 r � } 212 Main Street Phone (413) 58 -1240 F ax: ( 413 587 - 1272 ,_ F ,` ' " ` f y rro CY34"4Y =Y�^+Y/C' .a Building Commissioner - Anthony Patillo �k . . • : ,� ,�