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23D-051 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 owsconstruction 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 fonndation/footinas (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection or required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these in can result in; failure 'to obtain a certificate of occupancv 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 in pections. Failure of the individual trades to secure the permits and inspections as r quired can DELAY the project until such time as the proper permits and inspections are de 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 tome. Date 0 "' Address of work location 7 7 71 s 06(3 rr[1- The Commonwealth ofMassachusetts Department of Industrial Accidents. V► Office of Investigations 600 Washington Street Boston, MA 02111 z www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name Business/Organi ation/Indivich4 : • • • Address: City /State/Zip: Phone. #: Are you an employer? Check the appropriate box:. • Type of project (required) / 1.0 I am a employer with 4. [] I am a general contractor and I * have hired the sub-contractors -6_Q New cons truction__ emp loyees - (full and/or pairFtime).* 2._0 I arri a sole proprietor or partner listed on the attached sheet. 7. 0 Remodeling . . These sub- contractors - have. - -- — . ship' and have no eloyees 8. ❑Demolition working any capacity. employees and have workers' rking for me in Y aP aci ty 9 Building addition [No workers' comp. insurance • comp. insurance ,$ • • - re ed. 5. 0 We are a corporation and its 0.0 E ectrical repairs or additions 3 am a homeowner doing all work officers have :exercised their . 11.0 Pltmtbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required:] t c. I52, §1(4), and we have no employees. [No workers'' 13.0 Other • comp. insurance required.} *Any applicant that checks ' box #I must also fill out the section below their wosicers' 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 nnist.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 STOP WORK ORDER and a fine of up to 0.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Ines ' ations of the DIA for insurance coverage verification I hereby certi der th ains d penalties of perjury that the information provided above is true and correct S i g n a t u r e : - -- Date: • C fl r 369 l Phone #: S S • • 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 r 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 n a , ems' Not Applicable ❑ Company Name Registration Number Address Expiration Date — Telephone SECTION 10- INORKERS' COMPENSATION INSURANCE AFFIDAVIT ( G.L. c 152,. § 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 "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 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 thi • permit. The undersigned "homeowner" certifi - d ass I es responsibility for compliance with the State Building Code, City of Northampton Ordinances, State any ocal Zo g La ' d : to of I6 e - " General Laws Annotated. Homeowner Signature • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Acce sory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other [0] rief Description of Proposed 1 g - i � - rr - r E� tC Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No 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 . 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 , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date Ir , 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 nder the ains and enal 'es of perju . / P tName Signature of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Info ation Existing Proposed Required by Zorii g This column to be fil d in by Building Departmen Z Lot Size l . 1 ! 1 1 .,.,, --; ,..,„, . ; / Frontage 1 1 1 Setbacks Front t___._.__..! I 1 Side L:1 1 R:I 1 L:r l R:! 1 ..—._ P 1 Rear 1 1 1 1 I- Building Height 1 Bldg. Square Footage 1 1 1 1% 1 1 1 1 Open. Space Footage % � - _ _ (Lot area minus bldg & paved r ---- 7 r 1 j parking) - _ # of Parking Spaces ` i Fill: 1 (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued: i IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and /or Document #i j B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? ______ Needs to be obtained 0 Obtained , Date Issued: _._.____ T C. Do any signs exist on the property? YES ® 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 Q NO 0 IF YES, describe size, type and location: j 7 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. r ile City of Northampton I M Building Department ., , 7 ' $ � ;1, 3 0 212 Main Streets � hif Room 100 of Northampton, MA 01060 g : x z F { '�`" hone 413- 587 -1240 Fax 413- 587- 1272� � G a . vim= APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING CTION 1 -SITE INFORMATION .: 1.1 Property Address: This section to be;compieted by ,office 7 (n� Map t E.ci N ' Untt • C 7 %VCrSic9L -° 1)riv' -@ '* *eTrlay bistri::ct - Eiki kt. Di ,stf1ct CB D ist ifc t ' SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2 Owner of Record: +� t 6 r 1� s-' o. C YN ✓h u IA— 7 7 t ✓ /` ' N ame (Pero Current Mailing Address: 13 -5 Sy 3 6c1 .,,,,,,e.....‘ -�"�'� Telephone Signature 2.2 Authorized Agent Name (Print) Current Mailing Address: Signature Telephone SECTI 3 - ESTIMATED CONS COSTS It Estimated Cost (Dollars) to be Official Use Only com Ieted by permit applicant 1. Building © (a) Building Permit Fee 8! © 0 2. Electrical (b) Estimated Total Cost or Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number f/P ; 13' --- This Section For Official Use Only Date Building Permit Number: Issued Signature: Building CommissionerInspectorr Buildings Date 77 RIVERSIDE DR BP- 2011 -1117 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23D - 051 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: roofing BUILDING PERMIT Permit # BP- 2011 -1117 Project# JS- 2011 - 001796 Est. Cost: $8000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 11543.40 Owner: BRACHMAN GERALD R Zoning: URB(100)/ Applicant: BRACHMAN GERALD R AT: 77 RIVERSIDE DR Applicant Address: Phone: Insurance: 77 RIVERSIDE DR (413) 584 - 3264 () FLORENCEMA01062 ISSUED ON: 6/30/2011 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 6/30/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner