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24C-127 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 • • I NO . 1 0- .0 0 • $ - . 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 conjunction ta mitissued,_ 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, • 1 !_.* /�1 -! understand the above. (Home ow y ` /resid is signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Address of work location /6 Flan (d 4. S + 2-i - �/4n A44 Ol26O s The Commonwealth of Massachusetts Department of Industrial Accidents =Nii _ tiff Office of Investigations • _ 600 shre :3 : BostoWan, MA ington 02111 Stet � � www.mass gov /dia •Workers' Compensation Insurance Affidavit Builders/ Contractors /Electricians/Plumbers Applicant Information 0 `l lb t / Please Print Legibly Name ( Business /Organiiation/Indivirh : C J'(i � / - / j . - 12: \ 1`� Ne k Address: /0 S Fian fej,`,/, S 4-mss1- - City /State/Zip: i - Ad AM /61°60 Phone. #: 570 - a.2 ga.2, Are you an employer? Check the appropriate box: Type of project (required): // 1.0 I am a employer 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 2.0 I am a sole proprietor or partner- listed on the attached sheet 7. VI Remodeling ship and have . no employees These sub - contractors have. 8. ❑ Den►o;ition for me in any capacity. employees and have workers' working Y P tY- 9 0 Building addition [No workers' comp. insurance comp insurance.: required. 5. We are a corporation and its 10.0 Electrical repairs or additions 3.� I- am- a�emeewaerfiain ] o cers have'pxerc d_tli - - _ -1-1 lumbingrepairs 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. ❑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 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/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 $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of Investieations of the DIA for insurance coverage verification. . 1 do hereby certify under the pains and penalties o per'wy that the information nprovided_above is_true_andcorrec - _ . i j.. tune r /_i . 6 - _arrif O� L _ ate 03/ J / I _ Phone #: S —.2 Ali : 4), ; Official useonly. Do not write lit this areu, be compfetted by city or town officiaL City or Town: Permit/License # _ Issuing Authority (circle one): I Board of Health 2. Buihuing Department 3. City/Town Clerk 4. EIectrical Inspector 5. PIumbing Inspector 6.Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expirati ate Signature Telephone L.;RectitteredliomeirtfOroVestientContribtaiiii4t4S,Siii 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 ❑ 1144 Vint aWnergEradpnant 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 this permit. The undersigned "homeowner" certifies and assumes responsibility for c• pliance with the State Building Code, City of o amp on i tnances,' Spa e . n . - • • • . + ' r • sGeneral Laws Annotated. Homeowner Signature f / i' �i- 3 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition 0 Replacement Wi 1 s ows Alteration(s) Roofing ❑ Or Doors I! Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding [D] Other [0] Brief Decription of ro osed , , J I Work: L � Thitil A .)( � 4 0 r Ihr - 4 N rills — S W tr cL { � a f �QG. of ; FJ(15r' ¶ ep r i (1S Alteration of existing bedroom Yes )C No Adding new bedroom Yes r� N Attached Narrative Renovating unfinished basement Yes /_No Plans Attached Roll - Sheet west stew: fOilse a[> ar ac its` situ gicistinc °hn isinca,t oiip 4 itief f iiii: a. Use of b ild : One Family Two Family Other b. Number of rooms in ch family unit: Number of Bat •oms c. Is there a garage attached. d. Proposed Square footage of new c truction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance fonrn attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is carrstruction 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 1, . /-----".. as Owner of the subject AIM property hereby authorize t o act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, l E� :declare i�(' / L I7P - /7 ,Pf J( , as Owner /AtitfrtfR'led at hereby that he stated 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. Lc' 44►I1,at /L2sal e+L 14r1e— Print Name Signature of Owner /Agent ,.. P 4" Ff" Date } 1 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 i a _ __ ...e..... . _ . . .w.....__ .._. f f Frontag , : l Setbacks Front I 1 1 Side L: L:' .. R :j ....__.. i r...._ Rear _ ? _. ---° Building Height Bldg. Square Footage 1-7 i 1 % a € 1 r ° Open Space Footage /° I (Lot area minus bldg & paved parking) # of Parking Spaces t- -•- --- Fill: , ._� .e. _ q i (volume & Location) x•- s _' A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 9 YES 0 IF YES, date issued:; I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book ? 1 Page 1 and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW fp YES Q 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 IF YES, describe size, type and location: D: ;ire there any proposed'thiang to or a t io ns o iigns interred - Uor the property ? YES 0 NO a 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. L • I. ? s � i b rit fi 7, F K City of Northampton ti i ', Building Department w ' *6 t 212 Main Street . 1 r i - \Room 100 i e I orthaMpton, MA 01060 a Z.-� v ° 5 phone 41587 -1240 Fax 413 - 587 -1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION i This section to be completed by office 1.1 Property Address: 1,01? Frang t1n S+ Map Lot Unit N Dr1mn a r„,c,A , PO. A 004 ; Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT / 2.1 Owner of Record: - Name (Print) / ~ Current Mailing Address: Aj 4 /..A. �i I/ Telephone ff - a S `J 1- Signature J � ©- . 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' Si ��./ Q�, 00 (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 / 5° p .� ;Z 6. Total.- (1 +2 +3 +4 +g) Check Number . � � This Section For Official se Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File # BP- 2010 -0799 APPLICANT /CONTACT PERSON KIRK LISABETH & COLIN MILBERG ADDRESS /PHONE 1932 BANCROFT ST SAN DIEGO (619) 702 -4255 0 PROPERTY LOCATION 108 FRANKLIN ST MAP 24C PARCEL 127 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out �,Z n ,f� Ji1ZD�— Fee Paid NSW /" Typeof Construction: SHEETROCK,WINDOW REPLACEMENT, FLOOR REPAIR & DOOR INSTALLATION 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 INFQMATION 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 44cfr‘2(A—J 3)16 i 10 Signature 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. 108 FRANKLIN ST BP- 2010 -0799 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24C -127 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERIVIIT Permit # BP- 2010 -0799 Project # JS- 2010- 000642 Est. Cost: $25000.00 Fee: $200.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 9191.16 Owner: KIRK LISABETH & COLIN MILBERG Zoning: URB(1001 Applicant: KIRK LISABETH & COLIN MILBERG AT: 108 FRANKLIN S fi Applicant Address: Phone: Insurance: 108 FRANKLIN ST (510) 289 -2552 0 NORTHAMPTON MACA01060 ISSUED ON :3/16/2010 0 :00 :00 TO PERFORM THE FOLLOWING WORK :SHEETROCK,WINDOW REPLACEMENT, FLOOR REPAIR & DOOR INSTALLATION 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: Roug fE Rough: & /3 //d House # Foundation: Driveway Final: Final: 6,1 vo- inal: 67 j , Rough Frame: Gas: Fire Department Fireplace /Chimney: Hi' �y Rough: / ✓ f i' it) 4 Oil: Iasul:ction: Finale 3 - ■ a Smoke: T/2_4_ Final: et 6iTti t0 to t5 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAT N OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy6 r / rO (� Signature: FeeType: Date Paid: Amount: Building 3/16/2010 0:00:00 $200.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo