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39A-014 1 ,S) 2 \\./ )'-bt,1171°,'V ..............vr,...... r: 1 )54 A - 21 - ff ?-T-1 --('''° )1 QI svg?a, --N9 J. .._ _______ , ' $allY(26) ro9 ,5 Y 5 -'' ler2 -- Mil- "Pckco\-1/4\41. 1111 \'" ._01 I= ,s, j p.. • 0 ' Tay -'k))52.)10 an—l?-j - W-- — ...1-3\5 -- _if* r V g p) zt 1.7.-- s .......---'\ -8./NY 3.Mcivrr\ tie t — 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 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 r i A VIAP understand the above. (Home owner /resident' signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to Date (7t-3-to Address of work location a ^ a _ __.,. ' • - . . , The Commonwealth of Ilfassachusetts =-4--1-- Department of Industrial Accidents Office of Investiga . 600 Washington Street Boston, MA 02111 www.mass.gov/dia • • -Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Indivirbin1): Address: City/State/Zip: . Phone #: Are you an employer? Check the appropriate box: Type of project (required): I i.0 I am a employer with 4. 0 I am a general contractor and I 6. 0 New construction have hired the sub-contactors employees (full and/or part-tiroe).* listed on the attached sheet 7. 0 Remodeling 2. 0 I am a sole proprietor or partner- These sub-coniractors have ship and have no ›loyees 8• D Demolition etAiloyees and have workers' working for me m any capacity. 9. 013uilaing a.dition -. conip.insmaince_t_ 10.0 Electrical repairs or adcritions requirecL] 5. 0 We are a corporation and its 3. il am a homeowner doing all work officers havexercised their 11.0 Plumbing repairs or additions .,. myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comP- instance recluired-1 • *Any applicant that checks box #1 rairst also fill out the section below showing their workers' compensation policy infonnation. t Homeowners who submit this affidaVit indicating they are doing a]] 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/Stafe/Zip:' Attach a copy of the workers' compensation policy declaration page (showing the policy number and . _expiration date). Failure to secure coverage as requited uride Sect-la:I OfMGL c. 152 can lead to the iinpOsition of Crimiiiii 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 WORIC-ORDMR and a hie of up to 5250.00 a day against the violator. Be advised 'that a copy of this statement may be forwarded to the Office of Iiifons Of the DIA for insurance coverae Ve" . - - - -- ---- ---' ------'- 7, __ _ likikerebyTce ,' under the p , ' , / penalties of pejuryikat the infMmati'onprovidedizboe_Undiorrect.______ _. Si.i, • nue: L , „N.% A, Lart•41:41Iltik D aim- ' • w Phone #: ' 7177S ; - . Official use only. Do not write in this area, to be completed by city or WW1 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 #: E - SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9:1 ettisl r r iri lr r i ettireiit lii fia n, g gcr ;NtiTala 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 ❑ "i q »tGEt Ott # The current exemption for "homeowners" was extended to include Owner- occupied Dwellines 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 -vear 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 buildine 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 Zoni 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) 125 Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition A New Signs [O] Decks [1:7J Siding [O] Other [0] Brief Description of Proposed Work: rc jL LAY* (( 0klel fer1 - wlkh KW' coi/dreot LAfrelints Alteration of existing bedroom Yes No Adding new bedroom Yes No I &MO Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet t3a Miir aV' "aflc ief iddi n¢ iiftr aWu i pt te.tile folt"t wing: 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 l ` , as Owner of the subject property hereby authorize to act o my behalf, in all matters relative to work authorized by this building permit application. Sign ure of Owner Date I � rle ��L��r� , as Owner /Authorized Agent ereby declare that the statem nts 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. / L ,I •.A 414 Print N.. e / Signature of Owner /Agent Date , .r 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 Ii Lot Size ; Frontage I 11 i Setbacks Front = i F Side L:= ` R:i ( L:1 I R:I 1 s Rear i I I 1 Building Height 1-1 = d Bldg. Square Footage = 1% 1 t j t Open Space Footage % (Lot area minus bldg & paved ? ? -- parking) # of Parking Spaces Fill: 1 .._ (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO i1,�;4 DONT KNOW 0 YES 0 IF YES, date issued:i IF YES: Was the permit recorded at the Registry of Deeds? NO f DONT KNOW 0 YES 0 IF YES: enter Book i 1 Page ? and /or Document # __. B. Does the site contain a brook, body of water or wetlands? NO RI DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained , Date Issued C. Do any signs exist on the property? YES ® NO r�� IF YES, describe size, type and location: I D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO (' IF YES, describe size, type and location: i E. Will the construction activity disturb (clearing, grading, ex - vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO al/ IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • City of Northampton Building Department m , ; . 212 Main Street Room 100 Northampton, MA 01060 phone 413- 587 -1240 Fax 413 - 587 -1272 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 coNr Ave__ Map Lot Unit Zone ' Overlay District E rn St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: Telephone 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 com leted by permit applicant 1. Building E60, � (a) Building Pemmit Fee f(� 2. Electrical (b) Estimated Total Cost of v Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) S© 0 Check Number `3 .? This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date • File # BP- 2011 -0195 APPLICANT /CONTACT PERSON KENNEDY BRIAN y � C r t D C , ADDRESS/PHONE 22 WRIGHT AVE NORTHAMPTON (413) 387 -9973 Q 1 1 0 (' f PROPERTY LOCATION 26 WRIGHT AVE 0 'T N� ef A MAP 32C PARCEL 327 001 ZONE URC(100)/ k j Q ‘JA) THIS SECTION FOR OFFICIAL USE ONLY: ` OV— PERMIT APPLICATION CHECKLIST ��✓ ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out �� �� _ Fee Paid 1,5 Typeof Construction: REMOVE DECK & REPLACE W /TWO 5 X 8 LANDINGS & DEMO SHEDS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 --� / 91at g Si nature 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.