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23A-022 (3) } I 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 secu - re 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 permitissued,_ 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. Address of work location r • The Commonwealth of Massachusetts ;� Department of Industrial Accidents 1 t = :iv ' Office of Investigations • 600 Washington Street Boston, MA 02111 www.mass g ov/dia • -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Address: - City/State/Zip: Phone " #: Are you an employer? Check the appropriate box: Type of project (required): / 1. 0 I am a Y lo. er with 4.. 0 I am a general contractor and I 6. 0 New construction employees (full and/or part time).* have hired the sub - contractors 2, I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have no enloyees These sub - contractors have. .g. 0 Demolition working for me in an aci employees and have workers' Y capacity. $ 9 0 Building addition [No workers' comp. insurance camp- msuraucP. _ - required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. 0 1 -am a homeowner-doing-all-work- - - - - officers-} veIxercisec .their _ x.1., 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. 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 them 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 Ls 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 $1500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a .ire of up to $250.00 a day against the violator: r;e advised that a copy of this statement may be forwarded to the Office of Investisations of the DIA for insurance coverage verification. I do hereby certify under the p - , penalties of perjury that the information provided _above_i _true_andcorrect. Si • .. I'.d,/':.c i! a a 7 / t Pho.. #: qiy s 9 5— Rci el _..„... . Ofcied use only. Do not write it this area, — tube eompCeted by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: /� Not Applicable ❑ Name of License Holder : 5 c ' `vim -b �* Q7T 411 License Number r- t0 644. S ( . •Ro.-t. -xce (14: Qld(2 Address Expiration ate L1/ 3— " ci Telephone 9 .: Home lmprovdment:COrntractor ,,_ , . ..._ , a - ¢, .,,,pia , :..t: o . .x'! Not Applicable ❑ 55c / CPA .buvnc' 1:x'1 7U Company Name Registration Number 0 Oct. JC S4-- f / A/4, D 10b.2 /0ii 9 // Address t, Expiraf n Date Telephone /.3'S'(�L/Pt 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 budding permit. Signed Affidavit Attached Yes ❑ No ❑ lli oI1Ve t er XtiriptiO 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 referenceto 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 Ur t s; Sta et LOVA — • 1 _ • • • tts6eneral Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing kr Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other [0] Brief Descciia jon of Proposed (� l r Work: "Pr- -' k �/`t�Csti� ts. i�l eLCG �f c t'c.'►? o ✓e. tN1 e +z l ,ns4 r! I I r Alteration of existing bedroom Yes No Adding new bedroom Yes Attached Narrative . Renovating unfinished basement Yes ✓'No Plans Attached Roll - Sheet 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 . 1. 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 1, C :vs '`./<-c ot - , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit appli tion. 4.- 6 / 7/7a Signature of Owner Date e 65 � rian b dme , as Owner /Authorized Agent hereby declare that the statements and in ormation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. S 9 McIYI Print Name _.: - dive o J;; . ;;!"'- ate • 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 .._ f __---______S Frontage ` €_._ . i . ' Setbacks Front 1 1 Side L ____.__' R:' L: _ R: ......, _ _€ Rear Building Height Bldg. Square Footage nrn : % I 1 t "' Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces ---,--j _ . _ - Fill: 1 _... ,.de�._. �.�,o�.�.,.M.� .o�..a.� �� �.� �� ;._ �.. .��� �,�,. __ _ (volume & Location) i - ' £ - -•-•-- -- -•- -- - ---_ A. Has a Special Permit /Variance /Finding r been issued for /on the site? NO 0 DONT KNOW YES 0 IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES 0 IF YES: enter Book ° I Page: 1 and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 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 NO IF YES, describe size, type and location: D: Are the any Fo osed Changes to or additions of ri inter ed fir the property ? YES ® NO YP P g P P Y• IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, ex on, 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. n City of Northampton Building Department�A 212 Main Street w Room 100 ,.. SuaFtua to w'° �dediaea L9 ` C ,� Northampton, MA 01060 phone 413 -587 -1240 Fax 413- 587 -1272 :Z x APPLICATION TOCONS"TRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: c21 S Kf It U Map Lot Unit g[O e GZ° P"i A ©(c0 - tone Overlay District EIrn:. St. 'District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current M " dd ss Cry"' � .- 1 ` ] P[4-7-if- Telephone Signature 2.2 Authorized Agent: Name (Print) a� -- Current Mailing Address: / 3 6- d f cad. Si. , Telephone SECTION 3 •'ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed bypermit applicant 1. Building k 5-C7 (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 Y , 6. Total = (1 + 2 + 3 + 4 + 5) r d Check Number 2 -. ✓ 3 55 This Section For Official Ilse Only Date Building Permit Number. Issued: Signature: Building Commissioner /Inspector of Buildings Date 1 ARST'` BP- 2010 -1116 GIS #: COMMONWEALTH OF MASSACHUSETTS 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- 2010 -1116 Project # JS- 2010- 001638 Est. Cost: $4250.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JESSE MONTGOMERY 077410 Lot Size(sq. ft.): 10802.88 Owner: PLATT CONSTANCE A Zoning: URB(100)/ Applicant: JESSE MONTGOMERY AT: 21 PARK ST Applicant Address: Phone: Insurance: P 0 BOX 329 (413) 585 -8482 LEEDSMA01053 ISSUED ON:6/9/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REPAIR PORCH ROOF & REPLACE W /ASPHALT SHINGLES 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 6/9/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo 21 PARK ST BP 2010 - 116 GIS #: COMM ON WEALTH OF MAS SACHUS ETTS Map:Block: 23A - 022 CITY OF NO RT HAM PTO N Lot: -001 PER CON TRAC T ING WITH UNREGIS CONTRACTORS Permit: Building DO NOT HAVE AC TO T HE GU ARAN TY FU ND (MGL C. 1 42A� ` F . Category: 2010 -1116 BUIL PEI�:MIT Permit # BP- Project # JS- 2010 - 001 Est. Cost: $4250.00 Fee: $55.00 PERMISSIONIS HEREBY GRANTED TO: ,,-,,' ,--; :CZ l Const. class: Contractor: License . Use Group: J ESSE MONTGOMERY 077410 Lot Size(sq. ft.) 10802.88 Owner: PLATT CONSTANCE A ( Ap li cant:.1E SSE MONTGOMERY ; .. Zoning: URB 1001/ A T: 21 PARK ST Applicant Address: Phone: Insurance: P O BOX 329 (413) 585 -8482 LEEDSMA01053 IS SUED ON :6/9/20100 :00 :00 TO PERFORM THE FOLLOWING WORK: REPAIR PORC ROOF & REP W /ASPHALT SHINGLE ACE S POST THIS CARD SO IT IS VISIBLE FROM THE STR Inspector of Plumbing Inspector of Wi ring D.P.W Building Inspector Underground: Service: Meter Footings: Rough: Rough: House Final: Foundation: Driveway Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: 9- /-3 ^/610C14//14/ THIS PERMIT MA BE REVOKED BY THE CITY OF RTHAMPTON UPO VIO LATION OF ANY OF ITS RULES AND RE _ • ‘#. y irt44040 Certificate of Occupanc ` nature: FeeType: Date Paid: Amount: Building 6/9/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 =1240, Fax: (413) 587- 1272 Building Commissioner - Anthony Patillo > c a rr-ek rya 'q9S `v'R • "r$Rf "+6 ' t�+I Ah. � ,v ��- � a