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38B-185 L 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 regui tions Th_ a insne_ctionp ocea &equi. es 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- con}unction_to the building.permit issued,_ 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 =-.....,,-- V L-1-7. , --"Ar- - -r- -.7.7.116. = 1o, — . , Office of Investigations 600 Washington Street Boston, MA 02111 . • www.mass:govidia . -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeEiblv Name (Business/Organization/Individual): etc Pej 4 ,, ', • Address: *51 S 1 1QTRACk. 12 -6 . . City/State/Zip: 1 - , \ VA-- 0103 \ ---- Phone #: 9( - 6 Fay r, I Are you an employer? Check . . ropriate box: Type of project (required): l' Warn a employer with Z____ • El I am a general contractor and I 6. 11 New constru.ction have hired die sub-contractors erriployees (full and/or part-time).* listed on the attached sheet. 7. lain 2. 9 I am a sole proprietor or partner- These sub-contractors have ship and have no enTloyees 8• 0 Demolition • ' working for me in any capacity. employees and have workers 9. 0 Building addition ' e.I ins uranc [No workers' comp. insurance comp . 10.0 Electrical repairs or additions required.] 5. 0 We are a corporation and its d their --1 repairs or additions 3. 0 I a am a-homeowner-doing-all-work _Offic.ems_haci.2%ercise , right of exemption per MGL myself [No workers' comp. 12.9 Roof repairs insurance required.] t • C. 152, §1(4), and we have no • • employees. [No workers' 13.0 Other comp. insurance repired.j *Any applicant that checks box #1 must also ffil 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 ernployees. If the sub-contractors have employees, they must provide their workers' comp. policy number. I anz an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site i_xformation. _ 4. _ 1,,t_ . i ( _ , Insurance Company Name: e 1\_,Q. ft_ _ A • • Policy # or Self Lic. #: (9 - 5 - 7 13 9 c) 9,)-- Expiration Date: - Job Site Address: 3'3 2g..-i Yi / , iuen—ikpk.,_\. 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 S1,500.00 arid/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a e of up to S250.00 a day against the violator. PI e advised that a copy of this statement may be forwarded to the OffiCe of Investieations of the DIA for ins • . • e coverane verification. I do hereby ce 357 nder ' an Ana.lties ofperjury that the information provided ..above_is_true suld_correct._____ Date: _ __I .... y si• ..ture: 41104MM A -- i t / 7 07 — Phone #: 9 — - 6 rai - - • - Official use only. Do no WTI& In - this to completed by el° or town officiaL City or Town: Permit/License # -- - - Issuing Authority (circle one): • I: Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbinawector 6. Other , • Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Su isor: Not Applicable ❑ Name of License Holder : l'(•'0 M,(Jcz. - Y'] / `f . J ...A. • 11' ( r �+ Ci1dG� �Q �1� ' r- 5/S - 9 0/ Address Expiration Date ' 1 4 IAA Signature Telephone 9:.Reoistered ,Home; lmprovementContractor ,. ..., . „<< } ,.:Y t..,., Not Applicable ❑ S i �4 - ram. tai Q..) S' �J—(�a3- (e Com an Name t/" J Registration Nu ber _ 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 " homeowine-s" 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 ort ampton •riinancos,_ a e a I _ 4' ' • • ` • •• •• + - Y - - 0 ° • .`° - sGeneral- ba -ws- Annotated. Homeowner Signature z SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacemen ndows Alteration(s) El Roofing E Ur Doors Accessory Bldg. ❑ Demolition El New Signs [O] Decks [[] Siding [0] Other [0] Brief DescriptionAf Proposed 1 Work: t �;�_Q (4 VI)? LAJwvArtivS 1! lu1vy ( t�( ,ef..R u, ticttc . 30 Alteration of existing bedroom Yes � ✓ PJ6" Adding new bedroom Yes +.No Attached Narrative Renovating unfinished basement Yes iRl'o Plans Attached Roll - Sheet 6 , Ne *hou$e= anctor addi ion'ta existi ng houstnq; complete the following: 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 la - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT /,10 I, 4 -...A.... 4/`! %• ►_ 91 -_- !j 4 - 0 , as Owner of the subject property hereby authorize » %ti , �, t !1 .. C-c to act on relative all matte my behalf, in matters r to wo authorized by this building permit application. / / /Y. 494 k l I l"7 101 Signature of Owner Date I �` T , ; , � �} „ i e , as Owner /Authorized Agent ereby declare at the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Sign p under the pains and pip 'es of perjury. - — ' ASo - ,�� Print Name \ ' 0 .--- °' ';‘-' I I .., - - , ■ - - — t 1 - - ( I __ 1- _____ Signature o'-= , ner /Agent Date _ Y • s 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 Frontage Setbacks Front Side L. R : .. L'..._._.._. R. ....,..._' Rear Building Height Bldg. Square Footage % l_ Open Space Footage chi (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume &Location) _ A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW' YES IF YES, date issued:- IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book Page, and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW # 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 a IF YES, describe size, type and location: —D — Are there any =proposed changes to or a ttions o signs intenZed te property ? YES (3 NO 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 J10 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton '5 o erm ` f � 5 � * Building Department � d V e . -i , f `� 212 Main Street Seuv S = 4D1irIO(tt Room 100 7 ws i •' , , ,ra i � s t phone 413- 587 -1240 Fax 413- 587 -1272 � 3 o j APPLICATION TO CONSTRUCT, ALTER, REPAIR. _RENOVATEISR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 SITE INFORMATION ��(�`� 1, c'vl 1.1 Property Address: This Gectiop to be completed by office ("e s � ` _ M ' z -- - tot Unit p Zone Overlay District "��✓ Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record e, x:! : = .% � -I-� t6/44,,,A '3 3. :., .3-1- . / iv -1142 v10 Name (Print) Current Mailing Address: fri //-6 i Z - I Telephone 3 Y? - Y 1 Signature 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 �l,��lJe rsv (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 /1 6, Total (1 + 2 + 3 + 4 + 5) ' Check Number . • This Section For Official UseOnlq ' Building Permit Number: Issued: Signature: I Buliding Commissioner /Inspector of Buildings Date iO4 0611.T ST BP- 2010 -0541 GIS #: COMMONWEALTH OF MASSACHUSETTS tap' :Bt ck; 388 - 185 CITY OF NORTHAMPTON I.ot; -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 -0541 Project # JS- 2010 - 000760 Est. Cost: $8000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RICHARD PALMISANO 89485 Lot Size(sq. ft.): 9321.84 Owner: POULIOT STEPHANIE & MICHAEL HOLLAND Zoning: URB(100)/ Applicant: RICHARD PALMISANO AT: 33 FORT ST Applicant Address: Phone: Insurance: 87 SHATTUCK RD (413) 549 - 6824 WC HADLEYMA01035 ISSUED ON:11/17/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS 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 11/17/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo