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29-420
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 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 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 4 ♦ ... 1 , . The Commonwealth of Massachusetts Department of Industrial Accidents wy _:'1� t .� Office of Investigations e. 600 Washington Street _. -_._ ® Boston, MA 02111 ;'�.�" • ' www.massgov /dia • - Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers Applicant Information Please Print Legibly Name ( Business / Organization /Indivirinai): . .: .,... Addr _ 'W1.d ' � l-k • . _ . l City /State/Zip: ° . \ S\ ;►.,.., . V Phone. #: S ci�� '1 C- C? - Are ou an employer? Check the appropriate box: - . Type of project (required): /' 1. I am a employer with ' 4. 0 I am a general contractor and I 6. ❑New construction employees (full and/or part- time).* have hired the sub- contractors 2.0 I atn a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and. have no employees These sub - contractors have. .8. 0 Demolition • working for me in any capacity. eagileyees and have workers' ,Q Building addition [No workers' comp. insu ante _ ed 5. 0 We are a corporation and its 10.(_] •: cal repairs or additions re l ffi h officers avex�xercised their 11. 3. 0 I am a homeowner doing all work � Q Imaabing repairs or additions myself [No workers' comp. right Of exemption per MGL 12. e/ Roof repairs insurance required] t c. 152, §1(4), and we have no o workers' 13.[] Other employees. [N comp. insurance required.}. - *Any applicant-that checks box #1 mist also fill out the section below showing ttteirworkers' con>peasation policy information: t Homeowners who submit this affidavit: indicating they are doing all work and then hire outside cont actors 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 notthose 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 Nam I- Name: \ & (' T � � . • Policy # or Self-ins. Lic. #: O 4&O I L `�1 0 C 0 0 Expiration Date: _ ' Job Site Address: � 1 d�,� c )-e. city /State/Zip:' ' )r 0 - Attach a copy of the workers' compensation policy declaration page' (showing the policy number and expiration date). Failure to secure covera - - - _. mip i '' cnmmj penalties of a a ge.as required under Section 25A of IvIGL`c: 152 can lead the ' -- ositton of - fine up to $1,500.00 and/or Mae-year imprisonment, as well as civil penalties is the form of a STOP WORK -ORDER and a fme of up to S250.00 a day against the violator. Be advised. 'that a copy of this statement maybe forwarded to the Office of Investiiiii ns of the for insurance covera¢e verification.. _ . . I do: hereb y cerk r fy under th r - e pauu penalties of perjury that the information provrdednbnve_usrrsr_andcorrect _ _.- _ .. Signature: palm: ' ate: ' - `"_lTS11 V Phone #: %---) 1 (v‘,3 .. _ • :. - - Offcial use only. Do not write in this area, to be completed by city or townoffciaL City or Town.: - Permit/License # -- Issuing Authority (circle one): :1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electricaljispector 5. PIumbing Inspector 6.Other • Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 1 C 1 LicAe Number Address 4 Expiration Date Signat e Telephone 8,. Recastered Hairteµltil iebient- it"raeliri ii k .ii } tkAg ... Not Applicable ❑ Com any ame Registration Number C c \e SA C e�.� ikt)4■ ce' ` Address Expiration Date J.)' 8'Tk) Telephone S4�' , (r, 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 bur ing permit. Signed Affidavit Attached Yes 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 buildine 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 D Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors CI Accessory Bldg. Cl Demolition ❑ New Signs [D] Decks [EJ Siding [0] Other [D] Brief cription of Propos Wcwk: ' eN k\rt-\\- tk -S1 Alteration of existing bedroom Ye s No Adding new bedroom Yes No I Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa;''!f-,h a it house wind c, tddItior ex� ti rq "a►1 s��iq,;c mii + e i oitt a ►�na: 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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT r V S ��" O �' \ c-2 , as Owner of the subject propert hereby authorize © V 1 to act on m half, i all matt + relative to work authorized by this building permit application. P / Signature of Owner Date I, ' D t ) 'd �j , as Owner /Authorized Agent hereby declare that the sta emen s 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. Print Name Signature of Owner /Agent 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 � e a ' Lot Size i i Frontage 1 Setbacks Front I s Side L R:! L:? 1 R:` r Rear = l i Building Height € / = 1 i Bldg. Square Footage I 1 % = i Open Space Footage % i (Lot area minus bldg &paved I _ l i parking) # of Parking Spaces Fill: (volume & Location) I i ° s ` i A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 F 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 Page' s and /or Document ft: B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: { 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 0 NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • e.. City of Northampton e e Sul!ding Department P � . '212 Main Street m}� ' �d Room 100 AUG 2 3 20tiorthampton, MA 01060 a ^` phone 413 -557 -1 Fax 413- 587 -1272 of T 7_ APPLICATION TO CONSTRUCT, A i r.TER, 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 :Ma Lot Unit 1P�'V� Zone -. ' OverlayDrst.ict T O 6--t (. EInt Dlstrlct ` CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: C . . k ‘ ) DS t_A '� c_z . 3 C - ri ve 1r - 2v % ems Name (PrinN Current Mailing Address: f; Y`-.1C\ Telephone 56- 43), Signature co � 2.2 Authorized Anent: \\ - Name (Prin Current Mailing Address: r)A31\1":rf.C:5-C" ccd Signature Telepe� 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 4 �� 6. Total= (1 +2 +3 +4 +5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 23 GOLDEN DR BP-2011-0156 GIs #: COMMONWEALTH OF MASSACHUSETTS Map :Block: 29 - 420 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-2011-0156 Project # JS- 2011- 000260 Est. Cost: $5000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BOB THIBODO ROOFING & SIDING 065699 Lot Size(sq. ft.): 26484.48 Owner: OSEPOWICZ DAVID & LISA Zoning: URA(100) / /WSP Applicant: BOB THIBODO ROOFING & SIDING AT: 23 GOLDEN DR Applicant Address: Phone: Insurance: P O BOX 201 (413) 527 -7663 0 WC NORTHAMPTONMAO1061 ISSUED ON :8/24/2010 0 :00 :00 TO PERFORM THE FOLLOWING WORK STRI P & SHINGLE ROOF 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 8/24/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner