Loading...
25C-257 OE j7- wnr r u li e, 0,4 / yJ Air ?g;1/ bi -27 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 foal 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 i:lermits 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 understand the above. (H 1 • • e owne - /resident's si • ature requesting exemption) I will all to schedule all required building inspections necessary for the building permit issued to me. Date Jaz& 3 7, l d t Address of work location . The Commonwealth ofMassachusetts Department of Indus Accidents • Pk .."...41::E= 1112 MSIIME El' Office of Investig,ations . 600 Washington Street Boston, MA 02111 www.mass.gov/dia . .. • -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly r. Name (Business/Organization/Indivirinni): geo-K - . , 1 • 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. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. 0 New construction listed on the attached sheet. 7. 0 Remodeling 2. 0 I am a sole proprietor or pariner- These sub-contractom have ship and haven° ›loyees .8. 0 Demolition • working for me in any capacity. eicrigoyees and have workers . , . 9. 0 Building arciiiitin in,. I conip.—.1r-xnc _ _ [No workers' co. insurance _ _ _ 0 We are a corporation and 10.0 Electrical repairs or additions its -• *, ed.] 3. 0 am a homeowner doing all work officers havexercised their . 11.0 Pluming repairs or additions b nyself. [No workers' comp. right Of exemption per MGL r-1 „ - I/1_1 Roof repairs . • • , . ce required.] t ' c. 152, § 1(4), and we have no - 12.0 a .. , employees. [No workers' comp. insurance required.] • ' *Any applicant -that checks box #.1 trust also fill out the section below showing their workers' compensation policy infonration. t Homeownera who submit this affidaVit indicating they am doing all work and then hire outside =tractors must submit a new affidavit indicating such. :Contract= 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-contactors have employees, they must provide their workers' comp. policy number. /am an employer that is providing workers' compensation insurance for my einployees. Below is the policy and job site information. . . • Insurance Company Name: . Expiration Policy # or Self-ins. Lic. # i Date: - - Job Site Address City/Sta&Zip:' Attach a copy of the workers' compensation policy declaration page (showing the policy numl:Her and expiration date). Failure to secure coverage as required urider Sectiiiii25A c. 152 can lead to the imposition of Criniinil Penalties of a fine up to $1,500.00 and/or one-year imprisonment as well as civil penahies in the form of; STOP WORIC-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 Ofifce of trifeitiaations of the DIA for insurance Cove Verification. ( Ida hereby certi under the p • and pen ' s ofperjury that the information provided:a boveis_true_and_correct. _ • 1 • Signatire: /nfi Ilt/ 471 _ - Dat: cili 3 • k_ Phone #: / . 3— VV.—. S fiso - - • - 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 f• . • Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of LIcAnse Holder : License Number Address 1 Expiration Date Signature Telephone x, p a Not � , f . � m . « .:rn nforl 'ry �,:, ._.�,. Applicable ❑ Com • an ; me ` Registration Number Addres: 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. gned Affidavit Attached Yes U 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 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 i SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) E] Roofing E ,—,/ Or Doors El 2 Accessory Bldg. E Demolition ❑ New Signs [❑] Decks [❑ Siding [p] Other [CO Brief Description of Proposed Work: r{ rc f I,/ t r rfi If (AT/ t 1 Alteration of existing bedroom Yes r X No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes � No Plans Attached Roll - Sheet Of if a i' hnfkrf . f O Miii ad it i%liWAbliV` a rit Wei: 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 atta ed? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or oodstoves Number of each g. Energy Conservation Compliance. Mas - eck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor belowfirnfi(ied grade k. Will building conform to the Building and Zoning regulations? N ` , 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, , 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, J ti- r Sc v( h I ) a 1't d f , as t' uthorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the • - of my knowledge and belief. Signed under the pains and penalties of perjury. / J r 5 l4 4")... r,, , Print Name Alit Sign- re of • '/ gent Date i 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 De,artm• ' Lot Size I i i Frontage II (1 Setbacks Front / "( ` Side L: I R:1 i R:' , 1 1 , a�.� F Rear 1 1 /` Building Height �,,,, i Bldg. Square Footage 1 11, °/1 1 1 �` Open Space Footage - z % - (Lot area minus bldg &paved / 1 , \. . parking) # of Parking Spaces / i I Fill: 4 1 j (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO.,,, O DONT KNOW 0 YES 0 IF YES, dal i sued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 : r. ` . IF YES: enter Book . , Pagel ,/ I and /or Document # B. Does the site contain a brook, body ofAvater or wetlands ? / / (O ' DONT KNOW 0 YES 0 IF' YES, has a permit been or need to be obtained fr the Conservation Commission? Needs to be obtained ® Obtaineid'� ,Date Issued: C. Do any signs exist on the property? YE 5` - x+10 ����� �� / IF YES, describe size, type and ration: I 1 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: 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 ® NO ®- IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 9 x:93 $ s Li7 4 � City;of Northampton ------ Building , Department 3 :: 212 Main Street JUN 4 lORoom 100�n_�e� __. Northampton,. MA 01060 ae = phone 413 -587 -1 ?40 Fax 413- 587 -1272 _ ; APPLICATION TO CONSTRUCT; At1ER, 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: j f-4 r , - s t Map Lot unit I1)O p t k M � d l ©to d - Zone OverlayDistrlct Ekn St. ptatract' ': CB. District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT T 2.1 Owner of Record: J4 mQS t Sa1.d ti i /u r o f i S �a �r St -� J,/u =1h ti, MA 0/064 • Name Print) t Current Mailing Address: Li —,s 1 /1111 �j % 11(4 f Telephone 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION i COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 2-i 5.° v (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of S ct) Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection -} 6. Total = (1 + 2 + 3 + 4 + 5) Check Number / IY t 3 This Section For Official! Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File # BP- 2010 -1104 APPLICANT /CONTACT PERSON FOUNDS STEVE & SANDRA ADDRESS/PHONE 2631 GLENCHESTER RD WEXFORD PROPERTY LOCATION 15 FAIR ST MAP 25C PARCEL 257 001 ZONE SC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INSTALL DRYWALL 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 INFORMATION 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 / 2/10 Signa re of Building fficial 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. V rifzevi 1 (5,7) f"%i .CI o 53 ----- ,j 0 /� 15 FAIR ST BP- 2010 -1104 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C - 257 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Non structural interior renovations BUILDING PERMIT Permit # BP- 2010 -1104 Project # JS- 2010- 001354 Est. Cost: $3000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 8450.64 Owner: FOUNDS STEVE & SANDRA Zoning: SC(100)/ Applicant: FOUNDS STEVE & SANDRA AT: 15 FAIR ST Applicant Address: Phone: Insurance: 2631 GLENCHESTER RD W EXFORDPA15090 ISSUED ON:6/10/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL DRYWALL 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: 5 4 %, O' r'`" ' 1ouse # Foundation: s"/ /8/, ,4dp.rsl'„ i.r riveway Final: C/ Final: Final: ( 04> Ve0 Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: of< r tck THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. 0 4441 /AA tot4e0L Certificate of Occupancy '1 (0 - C�Signature: FeeType: Date Paid: Amount: Building 6/10/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo