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29-169 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 hone owner exemption, ° act as their own construdign 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/footines (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 •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 DELAY the project until such time as the proper permits and inspections are made I, 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 to Date Address of work location The Commonwealth of Massachusetts ►*= _ o/ Department oflndustrial Accidents • --9 a ' Office of Investigations • • _ 600 Washington Street 4— ;y Boston, MA 02111 yr 'Z1r ' www.mass s ov /dia • -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers - Applicant Information Please Print Legibly Name ( Business / Organization /Individual):. esSc 7'1 4 5 '' ('''^ _` • • Address: 40 O ck < Si-. - . , . City /State/Zip: e[olcv\c_c - . O(062 Phone. #: k ( 3 ^ sf f �'1 - Are you an employer? Check the appropriate' box: • . Type of project (required): / 1. I am a employer with 4.. o I &n a general contractor and I employees (fall and/ part time have hired - the sub co ntr a c to rs 6. ❑New cons�ttvction listed on the attached sheet 7. ❑.Remodeling 2.0 I am a 'sole proprietor orparmer- ship and Nava no rloyees These sub - contractors have .8. 0 Demolition " . working forme hi any capacity eir�Ioy workers' • [Ne workers comp. - cow' 10. IIectacal . - requfral] 5. 0 We are a corporation and its repairs or additions ir 3.0 I am a homeowner doing all work officers have xercised their . 11.0 Plumbing repair or additions m el£ No workers' co rift of exemption per MGL 3's comp. 12.0 nom repairs • insurance required.] r • c: 152, §1(4); and we have no • employees: No workers' . 13ErOther k..j.co. a :t -»u P . : - CO mp, insito roe reclOiCed-j . . . *Any applicant mat checks box #d :must also fiIl out the section belaashowing theaworloers' compensation policy information: t Homeowners who submit this affidavit,indicanng they are doing all work and then hire outside contractors mast submit a new affidavit indicating suet. :Contractors th check this box must antached an additional sheet showing the nacre of the sub - contractors grid slat whether-or notthosce ithies have employees. lithe sub - contractors have empkryees, they must provide their workers' comp. poky number. , . I am an employer than is providing workers' compensation insurance for iny employees Below is the policy and job site information Insurance Company Name Al - !"N v k vet.. k t ,,v5, C o . • Policy # or Self-ins. Lic. #: Combo L. 0. 4t . 0 ::P1 1 :14 b Expira Date: 3 / I a'C • Iob Site Address: 80 (...rPf .' k ° . City/State/Ztp iT14 - . •e t 0 r Attach a copy of the workers' compensation policy declaration page'(showing the p9hcy number.: and_ezxiration date). Failure to secure covera: .. ge r _" tinder Secfitm °25A of1vIGL a -152` can le to the . - - egmm-ed " - - iumposit<on of"cannnt}I penaltzes of a fine up to $ I, 500.00 and/or one -year imprisonment;' as well as civil .penalties im, the form OA STOP WORIK -ORDER and a fine of up to S250.00 a day against the violator Be advised That a copy of this statement may be forwarded to the Office of Tvestiaations of the Da - for insurance covera2'e verification: _ fdo hereby- certify unde , , enalties ofperjury that the inf ormatien rovidedliba t ' S i �. cure: �pr-� . •_ _ a g . / l Phone#: Li f . 'c ' cu 6 CF� 8 - ... .. . . - O trial use only. Do not write in this are to be co `' - .71 .,�' y a, completed by c>ty or town affuiaL City or Town: .. Permit/License # Issuing Authority (circle one): :1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical,Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone #: • SECTION 8 - -- CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: [ �y�.�� Not Applicable ❑ Name of License Holder : J 55 e d M `dY�.' J cY71 9 10 License Number 1 -14 001/4. S4- PLY-c tla . 010i, /0 /7`—/.2 Address / Expiration Date 4 3-5ctS — cNcP2 S re • Telephone , Z; , Not PP Applicable ❑ �._,... 7e55e 71,, j f 1 `f Company Name Registration Number 44 Oc 1c 5-1-: /a I l f Address c �F Expirati n Dafe P\4 t9t Oct Telephone x( 53 Jtda — SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L c.152,;§ 25C16» 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 ❑ R. i i wllert " =mon 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 0 Addition ❑ Replacement Windows Alteration(s) [J Roofing D Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [[] Siding [0] Other Brief Descrip ' of Proposed Work: r C rt.e C� kC� L�► �4 c ea /'/y wr; + •-� $ ✓ C a+ t w, Alteration of existing bedroom Yes Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes Plans Attached Roll - Sheet �,. '&166'4' 'WA 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 ,per /� 57Ct i/ � `� ' R , e e , as Owner of the subject property hereby authorize to act on my behalf i�� 1: tive to work authorized by this building perrni p Iication. /ff Signature of Own AS Date l 57 '#4e'°7 O3 �� 55' ,/' i�L -'j , as Owner /Authorized Agent hereby declare that the statements d information on the foregoi application are true and accurate, to the best of my knowledge and belief. Signed under the pains and h penalties of perjury. i r +'l r -7C.SS a f, aarair Print Name I Signature rOwner /A n Date • • Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information . Existing Proposed Required by Zo ,ding x This column to be led in by i " .i✓" a", Building Departm t x 4 Lot Size i 4 Frontage : ' ' ' Setbacks Front j �-1 i Side L: R: 1 L:; 1 R:`__...._ Rear 1 . Ell Building Height 1 i i Bldg. Square Footage g--'-- °�' -'1 % 1 E 1 ( i r Open Space Footage (Lot area minus bldg &paved i j i 1 ... parking) # of Parking Spaces `- --- Fill: ._d (volume & Location) ` i i A. Has a Special Permit /Variance /Finding er been issued for /on the site? NO 0 DONT KNOW YES 0 t 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 1 Pagel i and /or Document #' B. Does the site contain a brook, body of water or wetlands? NO " DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ,Date Issued: C. Do any signs exist on the property? YES 0 NO Cr IF YES, describe size, type and location: 1 i D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO IF YES, describe size, type and location: I E. WiII the construction activity disturb (clearing, grading, ex ion, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES C NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ' 114 yr. o mg cke 0\j L City of Northampton" �1 Building Department a �� ,�g`Z © 212 Main Street R ~' 1 Room 100 �,5 orthampton, MA 01060 oN 41 °. one 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 1.1 Property Address: This section to be completed by office tS v 4e Map L Unit C (��c,nc -e 14. 010G. Zone Overlay „Distract Elm: St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: c h e,-. Cdr: texe q« Name (Print) Current Mailing Address: n _ I e 6 1 � ` Q o , 1 Telephone Signature 2.2 Authorized Agent: �es5 e cr kp O s4 . � /Q'� -� `E 414, Name (Print) Current Mailing Address: t3 -S8S cfkid Sign / Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (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) I'� .5 0. Check Number This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building ICommissioner/Inspector of Buildings Date File # BP- 2012 -0200 APPLICANT /CONTACT PERSON JESSE MONTGOMERY ADDRESS/PHONE P 0 BOX 329 LEEDS (413) 585 -8482 PROPERTY LOCATION 80 DEERFIELD DR MAP 29 PARCEL 169 001 ZONE URA(100) / /WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out y� f Fee Paid j ((% 41(L5 Typeof Construction: REPLACE WATER DAMAGED DRYWALL & INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 077410 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 0171 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. 80 DEERFIELD DR BP- 2012 -0200 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 169 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 PERMIT Permit # BP- 2012 -0200 Project # JS- 2012 - 000307 Est. Cost: $5000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JESSE MONTGOMERY 077410 Lot Size(sq. ft.): 32931.36 Owner: BRACKETT STEPHEN J & KAREN A Zoning: URA(100) //WSP II Applicant: JESSE MONTGOMERY AT: 80 DEERFIELD DR Applicant Address: Phone: Insurance: 40 OAK ST (413) 585 -8482 FLOREN CEMA01062 ISSUED ON:9/9/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE WATER DAMAGED DRYWALL & INSULATION 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 8/31/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner