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41-025 ! ! 4 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 jermits 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 Date Address of work location 14 Commonwealth of Massachusetts Department of Industrial Accidents ' gP=77 f Office of Investigalions ,r Eim 1=----• s 600 Washington Street Boston, MA 02111 • " www mass gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legiblv Name pusinessiorganizationrindividuaD: i t ., - 2* 6 bt L o ti.. ,A ; r 0-, 1 ' 6 e• t' Al it )0K5 Address: "5 .,2 t. ,01,/, az. Cr. . • - City/State/Zip:AhAT 4 At GY4. Di° (JO Phone #: CI& — 2% ;--- Are you an employer? Check the appropriate box: Type of project (required): / 1.0 I am a employer with 3 4. 0 I am a general contractor and I 6. D New • construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet 7• 0 R.emodeline-, 2.0 I am a sole proprietor or partner- • ship and have no e,.wloyees These sub-contractors have 8. D Deraolidon employees and have worl:ers' • working for me ia any capacity. 9 CT Buildin g addition comn f . [No workers' comp. insurance _ p.iswa-nre _..____ requ]red.] 5. 0 We are a corporation and its 10Li .- Electrical repairs or additions 3. 0 I am a homeowner doing all work officers have txercisecl their t 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance regaired.] t c. 152, §1(4), and we have no er employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant -that checks box #1 must also fill out the section below showirtg their woricers 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. Contracto 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. lithe sub-contractors have employees, they must provide their workers' comp. policy number. lam an employer that 'is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: p 6.0ki-c-- 5 4 . ,,,1/21/5 • Policy # or Self-ins. Lic. #: a/ C. I 5 T� 6 3 9 9 l Expiration Date: - S j , Q c) I 1 „ .Tob Sift Address: it .33 OF-ST 1.-114 40, - ' City/Sint:clap: I/ i tiAt ,• I , AOC; d Attach a copy of the workers' compensation policy declaration page (showing the policy numb' er and expiration date). _ • _ Failure to secure coverage as required under Sectiiiir 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 5250.00 a day against the violator. Be advised that a copy of tliis statement may be forwarded to the Office of ,. Infeitikitions af the DIA for ....__, "..„...s I do hereby ce - under the pains and penalties ofpetjray that the information provided_abov.e. is_true_antiorrect._________ Signature: '' /t--Dr , •Da: i bi 61611 06 /.O ci Phone 4: I 1 • Official use only. Do not write in tit& ai to be completed by city or townitfficial • 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 , • i- • Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9.:Registerd.tnirrid lmgrovenieitt't ± ontractor,. �, , - 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 ❑ 11. - 16itit d erEitm ion 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 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 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 Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature r' SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) 0 Roofing Or Doors ❑ K Accessory Bldg. ❑ Demolition El New Signs [0] Decks [[] Siding [0] Other [0] Brief Description of Proposed i � Work: Sit i fl Kx.• is-co/co ,y (-t ( A/ C., l i s Piz Pi`Icd Alteration of existing bedroom Yes No Adding new bedroom Yes - No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a `if Viiii ii otllse:aind or additi6i teffe l titidliii iithill, `6ii iiiiiiilte 64:466: 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, (3 G� ALT r5 (.,6 , as Owner of the subject property y � . , hereby authorize CA U i 0 1 U /ter (G to act on my behalf, in all matters relative to wo0 authorized by this building permit application. Q Signature of Owner Date I, 4 v f n (- t t2 4 , as Owner/ uthonz Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of wledge and belief. Signed under the pains and penalties of perjury. QA✓i0 i'd: ttit Print Name /" �t 1 0 Jo(> 1 010 Signature of Owne 2 Y ' nt 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 Lot Size , ` __ ,. , _ ..—. ... —_... __. Frontage t , , 1 - -. Setbacks Front mm E ? F Side L: R: 1 L:? . R:' . , Rear = c Building Height [J '-" Bldg. Square Footage f i i % r i Open Space Footage % (Lot area minus bldg & paved j ��. s S parking) # of Parking Spaces i 1 _ ` Fill: E (volume & Location) z A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 i IF YES, date issued:1 IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q 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 Q 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 0 , 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 0 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. t City of No s ® T 1 �x -- Building Department ° q Al - . 2'2 Rain Street S� 1° ° � 1 �� Room 100 ' r; , , 8 C v'( � Northampton, MA 01060 ' �' Ff �« F . phone 41' 40 Fax 413- 587 -1272 ° ` E T ., APPLICATION TO CONSTRUCT, 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: 1 1 3 3 - srNA/11/'t t'J4)) /R°. Map Lot Unit Zone Overlay District Elm St District CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: `Rc p tz r V? LL tr 1-,. (l) - rco,Q ' , Name (Print) Current Mailjngi ddress _ © 6 Telephone Signature 2.2 Authorized Agent: L D ro•2 i l(3 4. 3 L Au tzz &i tik rlai M - Name (P ' t) 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' p (a) Building Permit Fee 2. Electrical 0 (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire ,1513 6. Total = (1 + 2 + 3 + 4 + 5) Check Number / v This Section For Official Use Only uc Date Building Permit Number: Issued: Signature: -+ io (0 Building Commissioner /Inspector of Buildings Date e t f �.;> BP- 2011 -0388 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- 2011 -0388 Project # JS- 2011- 000646 Est. Cost: $8000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DAVID FORTIER 008026 Lot Size(sq. ft.): 87120.00 Owner: DOYLE ROBERT D & MARGARET A Zoning: RR(100) //WSP II Applicant: DAVID FORTIER AT: 1133 WESTHAMPTON RD Applicant Address: Phone: Insurance: 32 Laurel St (413) 586 -8965 NORTHAMPTONMA01060 ISSUED ON:10/27/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: STRI P & SHINGLE ROOF 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 10/27/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner