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31B-045 • • 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 backfdl), 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 iermits 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 Y the .roject til such time as th- =roper permits and inspections are made / �� �L understand the above. (H s me ,• • n • /resident's sign ture requesting exemption) I will call t o schedule . - ' ed s uilding inspections necessary for the building permit issued to Date Address of work location • ? 1 . i , t The Commonwealth of Massachusetts Department of Industrial Accidents fig "" `" tf Office ce o Investigations � = � 'irl►� = - .ff f 91,1= 600 Washington Street 7a= f n ,, . -_ _ Boston, MA 02111 _ - . www.mass.gov /dia . -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers Applicant Information Please Print Legibly Name ( Business /Organization/Indiviti „ a1): Address: City /State/Zip: - Phone. #: Are you an employer? Check the appropriate box: Type of project (required): / 1. Q I am a y lo. er with 4. 0 I am a general contractor and I . 6. Q New construction employees (full and/or part-time).* have hired the sub- contractors 2. Q I am a sole proprietor or partner- listed on the attached sheet 7. Q Remodeling ship and have no a .loyees These sub - contractors have 8. 0 Demolition working for me m any capacity. employees and_Ilaye workers' 9 QB $drug addition workers' comp: insurance -. c.Qlnp. insurance - -- - -- required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. 0 I am a homeowner doing all work officers have xercised their . 11. Plumbm r s ❑ g repairs or additions myself [No workers' comp. ri it of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no [No workers' 13.0 Other employees. [N 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 subrrnt this affidavit indicating they are doing all work and then hire outside contractors roust submit a new affidavit indicating omh ( Contractors that check this box must attached an additional sheet showing the nacre of the subcontractors and state whether or not those entities have employees. If the 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: 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 pplicy number and'expiration date). Failure to secure coverage: as required'underr Section 25A 'of MGL c. 152 can lead to the iMposi ion 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 f ne of up to $250.00 a day a_ amst the violator Be advised that a copy of this statement may be forwarded to the Office of Investigattions of th 1L1 for insuran e cov a verification. _ . _ s - _ , _ [de hereby �� allies of , ' p at the information rovided b oveis_true a rc correct ignature: i ...4- Rate: _ Phone # rt __ 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 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 i tfate dlCotiiiiii veil>riert ri etEreMeig , 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. - Hom Owner . mti 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 "homeo " - 7 fi-. - I :. s . es.onsib' 'ty for compliance with the State Building Code, City of f' • • Northampton Ordinances • . • i State of Massachusetts General Laws Annotated. / re e ,fle / Homeowner Signature �� SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [=1 Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [CI] Other [Dj of Description of Proposed •---� ^� r' Work i I�,/J C f Wq33 c( U V �i' 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 7a OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , 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 I, , 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 and penalties of perjury. L��J - -- // /dnt ''r:E1;fr- f of yawner ' gen — L V Date 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 i i 1 i a� -- Frontage I t i 1 i _ _.___. Setbacks Front ! i -, Side L: I R:I i L:3 ..i R:= _. Rear • Building Height Bldg. Square Footage ' I % 1 = t i Open Space Footage . (Lot area minus bldg & paved l L._..___ ( 1 . — parking) # of Parking Spaces I '- Fill: �_, __ _ f , m....._........_ (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 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book 1 P ag e i and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 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 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: i D. Are there any proposed changes to or additions of signs intended for the property ? YES Q 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 Q NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. � �, s e ' City of Northampton Building Department a _ = 4 212 Main Street 44 f `- Room 100 YES ` ; � � � = Northampton, MA 01060 0 ' gi c phone 413 - 587 -1240 Fax 413 - 587 -1272 ; �' 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 VC� S ( YG E M ap Lot Unit Zone Overlay Distr Eli St Drstrict CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: _ - 1� 17 S VIA vAGSi , Namme^(Print) /� Current Mailing AdrJrec�s r F , ( / 1 \A (Print) e �` `T �n`�� Telephone (� V Lf. Signature L 0 b k / E - 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 1. Building p-0 -0 1,./- (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 6. Total = (1 + 2 + 3 + 4 + 5) Check Number 4; e v2 '— This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date BP- 2011 -0332 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-2011-0332 Project # JS- 2011- 000545 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 5706.36 Owner: KIRBY MICHAEL A & LUCILLE J ST Zoning: URC(100)/ Applicant: KIRBY MICHAEL A & LUCILLE J ST AT: 17 SUMMER ST Applicant Address: Phone: Insurance: 17 SUMMER ST (413) 586 -8834 () NORTHAMPTONMA01060 ISSUED ON:10 /12/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL WOODSTOVE 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 10/12/2010 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner