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38B-162 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 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 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, 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. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations rzt 600 Washington Street y a Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information ( Please Print Legibly Name ( Business /Organization/Individual): \�1 ( \t St Address: P• 0 c')OK 321,c City /State /Zip: A NI tA S AS i`1 ! ' Phone #: 1 13 — ? j 3O - 23 9 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ 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 2. [At I am a sole proprietor or partner- listed on the attached sheet. 7. r] Remodeling ship and have no employees These sub-contactors have 8. Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10. ► 1 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.V Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.g Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation 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 51,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under h ains nd naltie of erjury that the information provided above is true and correct. yy I 2 ��/ of `7 Sigmture: Date: ! r Phone #: t 13' 33° 5 3 - Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: n Not Applicable ' Name of License Holder : �" �-L' A t g53 ►J J License Number ° q o'& fr otoo (J7/2,xx Address Expiratio Date 3 v - -.�23y Si nat re Telephone 9. Registered Home Improvement Contractor:', ;: Not Applicable ❑ C .sdr z co tJ o-- 1 no2 6 5 Company Name Registration Number k4 O,001 L11,51 Address Expiration Date ? Telephone 3 >o —$ 239 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 It No ❑ 11. Home Owner Exelittatioil 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 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 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 (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) fir Roofing lii Or Doors rat Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding [O] Other [01 Brief Descrigon of Proposed 1 1 te 6 Ilk Work: N.ijeo ate. - tVeL..I ,,cold N , ..3 W %►JctJuSS i c} eC11�K k AKIN J •-(- b Alteration of existing bedroom Yes K No Adding new bedroom Yes No ve_e ti'i Attached Narrative Renovating unfinished basement Yes DK No .0 c t- - Plans Attached Roll - Sheet 6a. If New house and or addition to 'existing housing, .complete the €otioviiinq: 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, sec$ 00 (k)©Ia , as Owner of the subject property hereby authorize U l 1_L f 66 S ci`i • to act on my behalf, in all matters relative to work - uthorized by this building permit application. / A'rf :Owner Date 1, W l LC-i 1\ (. 6 tIL , 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. tk) 1.-(.- 114k Sew Print Name i � �� ✓l /��//llJJ 414 2; O 9 Signature of Owner /Agent Date • ^ . ` 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 C ^7 TK '94 6_2wr, 8 ' Building Department Lut3iz« .--------------- Frontage Setbacks Front F1i- c__, Side L: D: L:C R Cr F-' _�� F� r-- R ear `� ^�--- ----- Building Height .. r��� �--/ s - � � Bldg. Squar Footage [---� % _ --- 7 r ^�� �_� �_��- _� Open Space Footage _ __- % (Lot u�om/mmomo&n�ou �/�l��/ L___J 1-s%11 parking) F�] ---,----- �—� # of Parking Spaces �-- _ Fill: (volume &c^cati^m A. Has a Special Permit/Variance/Finding ever been issued for/on the site? .� �� �� NO � DONT v_� YES «�� IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO K ) DONT KNOW YES �^ �� _____ ___ - _/ IF YES: enter Book Page and/or Document # �� B. Does the site contain a brook, body of water or wetlands? NO �� �� . DONT KNOW �~/ YES v� �� � IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained »- Obtained Date - - - v~� ��/ ' � ... _-______j C. Do any signs exist on the prope 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 0 NO 6 ------------- -------------- IF YES, describe size, type and location: _________ __________ E. WHt the construction activity disturb ng, gradingexcavation, or filling) over 1 acre oris it part of a common plan that wiH disturb over 1 acre? YE8y ) NO ��) �� �� IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 4 e lf rs�ort City of Northampton StatusofPettxit Building Department Ctr�b CritGQritrewa Permr �`^ 212 Main Street SeuesleAiabri�ty Room 100 Water/{tKel? Ava�Yefarlrty Northampton, MA 01060 Tv o; ets � tStrrictura 'fans phone 413 -587 -1240 Fax 413 -587 -1272 P)a ►t ns Of(ier Specif P 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 L � o>Z1 S� Ej , NY - 4 Lu+p p Lot Unit o ft M �b Zone i Overlay District E 1m.S - 9istrict CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 641 ` a tik \ �oiZr S N r (r 4\twt3T01•3 V Name (Print) �A, '_��+[J�Current Mailing Addres : 3 ( - 3 Lt C 1 "" , ji- ' Telephone n u C►=2C S= /)(f U „ (UT(4 C(- fi.(ST /.ve A. 0 uCKw t fE 2.2 Authorized Agent: w k LL AiS/\ (3.5 t P c) t( 3Z6 A ►4 ©t co- Na • - (Print) Current Mailing Address: / 2/1' /. • Si.o =tur Telephone 3 SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 2 a. c o (a) Building Permit Fee 2. Electrical O b (b) Estimated Total Cost of • Construction from (6) 3. Plumbing X60 © Building Permit Fee 4. Mechanical (HVAC) b i O 0 C7 5. Fire Protection 6. Totai = (1 + 2 + 3 + 4 + 5) 52 , o o Check Number ? i 2- This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date L l 'r fb .-- i ` L t- Et 61 t.' rz-t q ri ► File # BP- 2009 -0907 APPLICANT /CONTACT PERSON WILLIAM GIBSON ADDRESS /PHONE P 0 BOX 3265 AMHERST (413) 330 -5234 PROPERTY LOCATION 16 FORT ST MAP 38B PARCEL 162 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out �,r ?�� Fee Paid S 1�cJ Typeof Construction: RENOVATE KITCHEN /BATH, REMOVE NON - BEARING WALL, NEW ROOF/WINDOWS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 45988 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN. FtMATION 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 eit)/0 j- 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. { • { i • "• ' gym. JSJRIESJ INC. -3 Id DH Bay /Bow # Ai i Sash , x *' Filled ;..,� ENERGY STAR x k ,. �r " �v n r , 7 * `i f R <> roc i ; 0010 Lour —E Argon c_ — QURL IF IECI , � ,.* ' 3 1ANCE RATINGS •f a Solar Heat Gain Co efficient RMANCE RATINGS fit$ o- Air Leakage (U.S. /I -P) � fi r n s�`4, -�.. s i� K - -1 a a fixed set 01 emironmental ions a a � 0 � - � 5 r " roduct and does notwarrant the suitabi o f any `� . arature for other Product Performance information l �a 0 �a .i d � r 16 FORT ST BP- 2009 -0907 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B - 162 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- 2009 -0907 Project # JS- 2009 - 001329 Est. Cost: $52000.00 Fee: $312.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WILLIAM GIBSON_ _ 45988 Lot Size(sq. ft.): 5314.32 Owner: DUCKWORTIi JEFFREY & CHRIS Zoning: URB(100)// plicant: WILLIAMGIBSOh' 41'r. 1 Fnp-r qT — Applicant Address: -- - Phone: Insurance: P O BOX 3265 - (413) 330 -5234 . AMk - ISSUED ON:5/5/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: RENOVATE KITCHEN /BATH, REMOVE NON- BEARING WALL, NEW ROOF/WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: 0 1 ` s, -57-L Meter: ,,, Footings: Rough: 4., "/ ' r ' / _ Rough: t f 3/ House # Foundation: Driveway Final: Final: (& - 09-a Final: � I 7 , Rough Frame: ( t �-[; 7 CP raI& (_e- 57f0E- Gas: Fire Department Fireplace /Chimney: Rough; 0 s 4 _ Insulation: — D LBO Fin:a:1 6-4 0) Smoke: 4e-4c '. Final f..- il ..& 4 0 ! (,, tilV r 2CX57,..0 . a a. .te0-7- 0. THIS PERMIT MAY BE REVGKED BY THE CITY OF NORTAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS Certificate of Occu anc signature: FeeType: Date Paid: Amount: Building 5/5/2009 0:00:00 $? 12.0078 1 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissi ner - Anthony Patillo