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,t'-AV4/f , CERTIFICATE OF LIABILITY INSURANCE cA -, '
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIt3HTS UPON THE CERTLFICATE HOLDER. Ti-l15
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BELOW, rim CFIRTIriDAT OF INSURANCE DOES NOT CONSTITUTE A CONTRACT 'VEEP THE ISSUING 1NSURER(S). AUTHORIZED
REPRESENTATIVE OR PRODUCER, ANC THE CERTIFICATE HOLDER.
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L eetthcate Iaidpr in ffeu of siredt endoryernant(s}.
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01aB -2009 A NO CORPORATION. API rights reserved.
CORO 25 (2OD91091 The .ACMC carne And logo are registered martyr of ACORAI
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 1 08.3.4 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 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 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
iermits 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
understand the above.
(Hom ner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date / / /Ss /
Address
ation of work / y J c,L a / rck fry,( l location /
plc, -- M4
c� %b 6�
The Commonwealth opfassachusetts
Department of IndustrialAccidents
Office of Investigations .
600 Washington Street
• Boston, MA 02111
47., " www.mass.gov/dia . ....-.
...
Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
' Applicant Information Please Print Legibly
Name (Busines.i/OrganizationfindivichinD:
- Address: ,. .
City/State/Zip: - Phone.#:
. -
Are you an employer? Check the appropriate box: Type of project (required): l
1. 0 I am a employer with 4• 0 I am a general contractor and I
N
employees (full and/or part-time).* have hired the sub-contractors 6. 0 New construction
lis'ted on theattached. sheet 7• 0 Remodel-11,r
2. 0 I an a sole proprietor or partner-
. ship and have n.9 -,Ioyee.:s These sub-contractors have. 8. 0 Dennolidon
ercployeesand have wOrkers'
working for me in any capacity. 9 Q Building addition
[No workers' comp. insurance-
requir ecL] - 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. 0 I am a homeowner doing all work officers have 4 their . 11.0 Phunbing repairs or additions •
myself [No workers' comp. ri of exemption per MGL
12.0 Roof repairs . •
insurance required.) t e. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance reqiiirod.j. . *
*Any applicant that checks box #1- must also fill out the section below showing their workers compensation policy information. '7 •
I Homeownera who submit thii affidaVit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. -
:Contract= that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not thase entities have
employees If the sub-contractors have employees they must provide their workers' comp policy number.
Jam an employer that is providing workers' compensation insurance for my einployees. Below is the policy and job site
information. .
•
Insurance Company /same . .
Policy # or SeLf-ins. Lic. #: Expiration Date: - • -
Job Site Address: City/Statz/Zip:'
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required tinder Seetiiiir25KOfMGL'e. 1 can lead to the imposition of Min:final penalties of a
fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK-ORDER and a fine
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
rlikTeitiiiiiithis - 6f thi DIA. for insurance coverage ir . : . ,,
_ I do _ e rabycertib under the pains. d pen ofperjury that the informationprovided _abovicitm _and_correcr
ienature: a
y
.. .
- ' - - 13 ate: - N (s5 / • • ,
Phone #: c3 ' (-.// Ci fl'./5 - • - •
Official use only. Do not write in this &ea, to be completed by city - or town'Officie
City or Town Permit/License #
:
Issuing Authority (circle one):
.-
- .
:1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #: 6- .
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
8,'Re.. tar`s'. Ali' a 'roverne'sif o s '' A - ., rr a nzx ' qiikidiraMIS 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 ❑
1:,.1.1.1 MI IE�'lf % .a
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 Zonin Laws and S f Massachusetts General Laws Annotated.
4E, omeowner Signature \,,,_,2
•
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. El Demolition El New Signs [D] Decks [(] Siding [D] Other [0]
�nef Description of Proposed
i' pork: ill S 7 ii /b CJ/ C 0 of C (A) 4o ri 3'7 ov
Alteration of existing bedroom Yes V No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes It No
Plans Attached Roll - Sheet
sa f ri alturr it c pia lrsin . p atf> iardi ta:
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
I, , 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
I, 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 he pains and penalties of perjury.
(V.JJC L-Ov (
Print e r N ^ p / I 0
V Z / / /�: /
ignature of Owner g t Date
a
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 L . 1 r_____
Frontage r i
Setbacks Front i I ' z
Side L:i R:: i L:l 1 R:1
Rear = L] 1
Building Height I L 1
Bldg. Square Footage t I # % 1
Open Space Footage %
(Lot area minus bldg & paved _ . ' _ -
£ Sri n...
parking)
r ! ,
# of Parking Spaces - _.
Fill:
(volume & Location) i.€
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book ! Pagel ! and /or Document it:
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ,Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES t NO Q
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton k ,5 r�
•
Building Department
212 Main Street m� if "
Room 100 g
Northampton, MA 01060 a i }
p hone 413 - 587 -1240 Fax 413 - 587 -1272 � �'
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION ` - SITE INFORMATION
This section to be completed by office
1.1 Property Address: � —~ [, f
i,1 �CJ IA /R� / �' ! I Map Lo �7 U nit l
p�� ( g
1 _ /, _ ✓t .a Al done �� Overlay District
Elm St" District Ds District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
A( � / 1 , �� (8I, 6, . Tom / rjc>,, , ��
me (Prin Current Mailing Address: z4) z} ;7 7 / i �( s _
J
Telephone
Signature
2.2 Authorize gent:
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 1 /S Q Q 00 (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= (1 +2 +3 +4 +5) Check Number / 0J
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings - Date
BP- 2011 -0451
GIS # COMMONWEALTH OF MASSACHUSETTS
.3746$ . CITY OF NORTHAMPTON
Lot: -024 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0451
Project # JS- 2011 - 000731
Est. Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): Owner: LOVELL ALYSSA
Zoning: sr Applicant: LOVELL ALYSSA
AT: 124 BLACK BIRCH TRL
Applicant Address: Phone: Insurance:
124 BLACK BIRCH TR (413) 219 -1745 ()
FLORENCEMA01062 ISSUED ON:11 /15/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WOODSTOVE
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 11/15/2010 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner