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17A-067 • 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, act as their own constra&rpn 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 occu anc 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 jennits 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 1 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 Date )) 11 Address of work location 0(06), , . .. . . : The Commonwealth of Massachusetts Department of Industrial Aecidents . ,.. g, ■ 2 E Office of Inivstig,ationS 600 Washington Street i Silif—= 47' Boston, MA 02111 . . . www.mass.gov/dia . ..- - Workers' Compensation Insurance Affidavit : Builders/Contractors/Electricians/Plumbers .... Applicant Information Please Print Leib1' = . . . = Name pusineseotg-4niiationfindiviiimo: CaTtil Lee ,, Kt 0.-s - Address: 22 t 4at•-, -i--- ,•• • . City/State/Zip: ft. 6 rCe (\A Pr 0 1 )-- Phone .#: - - . . „ Are you an employer? Check the appropriatebox: ' Type of project (required): l 1.0 I am a employer with 4. 0 I am a general contractor and I 6. 0 New construetion have hired the sub-contractors employees (fall ancVor part-time).*- 0 R.emodeli 2.0 I ani a sole pi-oprietor or partner- listed on theattached sheet. 7. si have These sub-contractors have. 0 .8. Deinialino n . . dpw2. lio employees working for me in any capacity. en:ffiloyees workers' ,,, i ._,,____ 0.4 r Ne equ i;d7 ke:IS I ? 7 1321); ingijiartee- . . 5. D W l' s u 12 n c e . " a colpoia: ti its 16 ai r adcriti ons • 3.t.bi I am a homeowner doing ill work officers haVettercised their . 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL r--1 124_1 Roof repans insurance required.] t ' c 152, §1(4), and We have mi - enployees. [No workers' • 13.0 Other , .. ' . • • comp. insurance reqiiired.j. - I . • •Any applicant tbat checks box #1 also fill out the section belowsbowieg theirivoricers compensation policy information.: t Homeovdnexi who submit this afficlivitincfidating they are doingall work and then hire outside contraetom must submit anew affidavit indicadng such. . Icontractars that check this box mustattached an additional sheet showing the name of the subcontractors and state whether or notthose-entities have employees. lithe sub-contractorshaVe employeeS, they mustpravidetheir wOrkeis' comp poky number. Jam an employer that is providing workers' compensation insurance for *my employees Below is the policyandjob• 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 pne the policy number andexpiration date). . . . , . Failure to secure coverage as required 'Miler SeCtiall'25.CotICIGL c 1526iii lead to iiinPoS, Of eriniinal penalties of a fine up to S1,500.00 and/or one imp/ism:me:4'as well as civil Penalties in the form of; STOP WORIC-ORDER and a ae of up to S250.00 a day against the yiolatcir. Be advised that a copy Of dais statement may be forwarded to tt.i.Clathice'of - frifeitiatiiiiiiTtifth - iDa - foiiiiiiiialie'e 6niiii'aii - - -. ' - ' 7 .......1;.... ..,.. -.;..::-,:,......„ _ / flo . ereby_e • ..: 1 up liar the pains s olpezjary that the informationprovideiritfroz find &Tied. . i mature: -, ' ' • - - - - - : T : 7 Da te: 5 2— . 77 . // • . . , . , Phone - it: - _ . • • • - Official use only. Do not write in this arezz, to be completed by cityii tOWnOkiciat • .City or Town: Issuing Authority (circle one): „ . . *- Permit/License # ' .,... .. . .1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector 6. Other . . . , li Contact Person: Phone #: li • . • • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9 „Aeiiisterettiii 'rn lrrietov mer$t tarif"acttir•. - �:, ,k a lidEga 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 ❑ 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, Sta nd Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature Lam- ,L SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) 18 Roofing El Or Doors ❑ Accessory Bldg, ❑ Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [0] Brief Descptiop of Propos d Work: (Led i f ...tti \� � � e kA41 -t'N t---NI V1 1 fte Cc hi , rot. te�i -,r�d� .�° 11 _� �Y � U.410 5� , MC:v¢ tv�� ��L^+�) f bvi i� bey Cr t)cset h� d v ° A)r t�t -� Alteration of existing bedroom Yes 2( No A ding bedroom Yes No Ui M ode tit Li- (a_ Attached Narrative Renovating unfinished basement Yes No eft Plans Attached Roll - Sheet y� h 6a If erns do ISe ar d cir., a dl o t x sfilttq [i�iusint�. Qmplete fhe fall uwiflQ: r��.�,., . 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 Ol ! liall•A1011lS• , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this budding permit application. Signature of Owner Date 1, II (Z C L trig 5 , 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 under the pains and penalties of perjury. Cc 1 It? ?„ L k VI e3 Prin a e c/ I Sigri ure of Owner /Agent Dat Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning n (" C \ �(kn�,i'� This column to be filled in by v :1 '`() Building Department Lot Size € ',A 1 000 5 • C. 1 ' • 1 1 i a Frontage _ oC 1 t ? , _ Setbacks Front El] i Side L: R: L: z R: Rear = _— Building Height Bldg. Square Footage a' = % t 1 1 1 i Open Space Footage % . I (Lot area minus bldg & paved 2' ,? rt _ -_. parking) # of Parking Spaces &Lin - Fill: r .—.. ,—... ..., € ..m,...a — _-.. ..�,v�,,., .,,�...,��... ,�,, (volume & Location) i 11 i - -- --, A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW ir. YES 0 1 IF YES, date issued:1 j IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book 1 g Page and /or Document #,„ B. Does the site contain a brook, body of water or wetlands? NO C41 DONT KNOW 0 YES 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 qi IF YES, describe size, type and location: t D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 6 IF YES, describe size, type and location: I E. Will the construction activity disturb (clearing, grading, a cavation, 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. s� us t e �` City of Northampton � p��� ii`` Building Department log \ 212 Main Street S k= tr ti Room 100 rt"O , = hampton, MA 01060 *�40�� �,r�� �s�" • o e 413- 587 -1240 Fax 413- 587 -1272 ��� APPLICATION TO CONSTRUCT, ALTER, - EPAIR ENOVATE R DEMOLISH A ONE OR TWO FAMILY DWELLING J SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 1\e QAi c eC Map " Lot Unit F l ore i L , nA l 0)0G-2_ Zone " Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Cad, lee,, L. K \cu3 5 c.is aJ,v Ve— Name rint) Current Mailing Address: L 4/13 6-L o 7'3 K%- Telephone Signs 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 permit applicant 1. Building J r� 00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of ✓� 5�� Construction from (6) 3. Plumbing S-0 O Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) Check Number 37 ` 3" -- This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -0987 APPLICANT /CONTACT PERSON KLAEZ CATHLEEN 5 t'\' KC' ADDRESS/PHONE 22 MOUNTAIN ST FLOREN CE (413) 626 -0693 0 L � ,� ✓� l 6 7E -� PROPERTY LOCATION 22 MOUNTAIN ST MAP 17A PARCEL 067 001 ZONE URA(100)/ /RI /WSP THIS SECTION FOR OFFICIAL USE ONLY: r y L 000- P 1- ` PERMIT APPLICATION CHECKLIST C ENCLOSED REQUIRED DATE 3 ZONING FORM FILLED OUT Fee Paid Building Permit Filled out (3 7r f � Fee Paid Tvpeof Construction:_ SHEETROK,KITCHEN CABINETS,CONSTRUCT CLOSET,RELOCATE W/D New Construction Non Structural interior renovations Addition to Existing ; Accessory Structure `( Building Plans Included: ` G Owner/ Statement or License #' 3 sets of Plans / Plot Plan VA" ��� THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 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.