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24D-084 • • 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 insrected. 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 ermits 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 DrLAY the project until such time as the proper permits and inspections are made 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 tame. Date Address of work location 1. The Commonwealth of Massachusetts � , ^ :_ Department of Industrial Accidents. • , w i► fit Office of Investigations E . _ _ in1_ ' 600 Washington Street Ta = Boston, MA 02111 " _,. '' www.massgov %dim -Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly r e .‹....z Name (Business/Organi ation/Individual) :. r`1 i i, vt • i (. • , Address: 1 I r L/ S `��. — . City/State/Zip: --1 1 ,3y e Lt & 1,kil at 0‘..)I Phone. #: 3 ? I:} /8 l 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 constru ion - - -- employees (full - and/or part : * — have hired the sub- eontraetors— ct ._ - - - -- - _ -- 2._ I am a sole proprietor or partner= listed on the attached sheet. 7 Remodeling ship anclhave no employees These sub- contractors - have — .8. ❑ Denolition working for me in any capacity. a 3' employees and have workers' ... 9: 0 Building addition [No workers' comp. insurance comp. insurance. req 5. 0 We are a corporation and its 10.0 Electrical repairs or additions - . h officers ave exercised 3.0 I am a homeowner doing all work o ,� their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs • insurance required] t • e• 152, § 1(4), and we have no employees. [No workers' 13.1: Other • comp. insurance_requied] 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who sulnnit this affidavit indicating they are doing all work and then hire outside contactors must submit a new affidavit indicating such. tContractors that check this box mist 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. Be advised that a copy of this statement may be forwarded to the Offce of Investigations of the DIA for ifsuranc cov,tge verification I do hereby certify under.", , , , penalties of peljury that the information provided above is e and correct -Sig.: tire: �. l , 7 '' ." / . Date: a _ / Phone #: ,/' - _ ,/& - 3 ( Official use only. Do not write in this area, to be completed by city or town official City or Town: PermtiLicense# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Y • Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicab tt (❑ Name of License Holder : r 1 �� � i (. • / License Number Address do Date titter , 0 1 06 Signature Telephone . it } ' Not Applicable ❑ Company Name / --� Registrati n N mber Address Expira ion ate iU1 c)04,_ L Telephone V — /S - / SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVITIKG.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. he Signed Affidavit Attached Yes NO No ❑ 1)._193 t.. 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 compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replac Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [0] Brief Description or Proposed, Work: l .E. � eta (f A.Lt 2 tAA 4 Alteration of existing bedroom Yes No Addin.e' , . -droom 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. WilLbuilding 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. I, , as Owner of the subject property J� hereby authorize /" 11 V►'t er to act on my behalf, in all made, relative to work authorized by this building permit application. S of Owner / Date 1, l l 11.1 IP,SC/a, , 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 under he pains a • . enalties of perjury. Aot t om__ Print Na = 1 ;4/22 Signature.. Owner /Age Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete) Information -. - - I,_ - Existing Proposed Required by Z' fl This cohunn to be tiled in by o ft B ill uilding Departm t Lot Size 1 I ..,. .,. - 5 Frontage I 11 1 Setbacks Front 1 1 Side L: R:= L:= R:= i _ . Rear I 1 1 1 1 Building Height = I Bldg. Square Footage _Open _ Space - Footage % - `-�- — I (Lot area minus bldg & paved = ! = 1----t parking) # of Parking Spaces r 1 I , Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Q YES Q I T I IF YES: enter Book I Page and /or Document #! , B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Q , Date Issued: 1 i C. Do any signs exist on the property? YES Q NO Q 1 IF YES, describe size, type and location: 1 `X / ' 1-: , � - D. Are there any proposed changes to or additions of signs intended for the'prpperty ? - )YES 6 NO i IF YES, describe size, type and location: 1 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 Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • ; IVED ity of Northampton uilding Department `gam a 212 Main Street 2 i ! Room 100 J M ' ;� e rthampton, MA 01060 � . , — - fi ''t � � of MA , s � = 41 :- 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 sec tion to be compieted by,office i. s P Lit $:..',.„:,-, ' 4Jmf /f iit v ; t ., :3r r v «4A-, r) \ V � �.(. -tr# 3t Ct .CB -District SECTION 2 PROPERirY OWNERSH[PIAUTH.ORIZED AGENT 2.1 Owner of Record: __ —. Name (Print) ) - -. Current Mailing Address: 4, � (. .� r Telephone � _ ��� G I is L / - V [j Signature L `j� /? S J� �i„ Z / J 2.2 Authorized Ager"C � � Name (Print { Current Mailing Address: f : / �� /e Signat ( f Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building . 0'U —.._ (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 Protection .14- 6. Total = (1 + 2 + 3 + 4 + 5) �i(i Check Number This Section For Official, Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /[nspeotor bui ldings : Date 145 KING ST BP- 2011 -1095 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 084 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit # BP- 2011 -1095 Project # JS- 2011- 001761 Est. Cost: $600.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KIM RESCIA 022464 Lot Size(sc . ft.): 29751.48 Owner: STANDICK TRUST Zoning: HB(100)/ Applicant: KIM RESCIA AT: 145 KING ST Applicant Address: Phone: Insurance: 311 Locust St (413) 320 -1831 0 FLORENCEMA01062 ISSUED ON: 6/27/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL 2 REPLACEMENT WINDOWS 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 6/27/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner 145 KING ST BP- 2011 -1095 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 084 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit# BP- 2011 -1095 Project # JS- 2011- 001761 Est. Cost: $600.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: : KIM RESCIA 022464 Lot Size(sq ft.): 29751.48 Owner: STANDICK TRUST Zonine: HB(100)/ Applicant: KIM RESCIA AT: 145 KiNO ST Applicant Address: Phone: Insurance: 311 Locust St (413) 320 -1831 () FLORENCEMA01062 ISSUED ON: 6/27/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL 2 REPLACEMENT WINDOWS 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: V1P�cr� Dou Final: Smoke: Final: P,26,, // oK THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. 1 4i4A4 ttittet4 Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 6/27/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner 145 KING ST BP- 2011 -1095 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 084 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PElRIVIIT Permit # BP- 2011 -1095 Project # JS- 2011- 001761 Est. Cost: $600.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KIM RESCIA 022464 Lot Size(sq. ft.): 29751.48 Owner: STANDICK TRUST Zoning: HB(100)/ Applicant: KIM RESCIA AT: 145 KING ST Applicant Address: Phone: Insurance: 311 Locust St (413) 320 -1831 () FLORENCEMA01062 ISSUED ON: 6/27/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 2 REPLACEMENT WINDOWS 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: V�1l Dot. Final: Smoke: Final: 9,26• /1 ©K THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. 1 6444 ils.tuftwil• Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 6/27/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner