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30A-039 , 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 me. Date Address of work location • . ` The Commonwealth of Massachusetts Department of f Industrial Accidents - _ 1,=. � Office of Investigations . 7. = a 600 Washington Street Boston, M4 02111 �7 - _ , www.massgov /din - Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information - Please Print Legibly Name usiness /Organization/Individlnal): �j / �' 0 / < 1� /„ Ot t J 71 �iv ( i ) • Address:) � )rie� . City /State/Zip: fi ,9h-, j o x) -, D l l/ � v Phone. #: v ti'6 l /e7 . Are u an employer? Check the appropriate box: • •Type of P roject (required): uir / 1. I am a employer with 4. 0 I am a general contractor and I empIoye and/or part-time).* have hired the sub- contractors 6. ❑New construction 2. .0 I aru a sole proprietor or partner- listed on the: attached sheet: 7. 0 Remodeling ship and have hp e loyees These sub - contractors have .8. Q Demolition • working for me in any capacity. employees gad have workers' 9: Bird a&!ition tom"' workers-'' comp. insurance CpInp. inctn anc-^ # .. Q _,.. `�` .:. required.] - 5. 0 We are a corporation and its 10.0 Electrical repairs or add'iti'ons 3. Q I am a homeowner doing all work officers havexercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.] t ' c. 152, §1(4), and we have no employees. [N 13. Other • o workers' . comp. insurance requued.j. *My applicant that checks box #1 must also fiII out the section below showing their commotion policy information. • . t Homeowners who submit this affidavit.indicaimg they are doing all work and then hire outside contractors must submit a new affidavit indicating such: Contractors that check this box mustatiached an additional sheet showing the name of the sub - contractors and state whether ornotthose entities have employees. Yale sub -cone actors have employees, they must provide their workers' cote. policy number. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information rA / Insurance Company Name: l / C.�Z,TX - //`/ L T �� /�l Policy # or Self- -ins: Lic. #: te C> „ 1 "Si ! / 9 Expiration Date: .45' y .c v I Job Site Address: rty/StafcJZip . Attach a copy of the workers' compensation policy declaration page (showing the policy numb" umber and expiration date). Failure to secure coverage as required udder. Section'25A ofMGL c: 152 can lead to the iutposition`of criminal penalties of a Erne 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 fe of up to S250.00 a day against the violator Be advised that a copy of this statement maybe forwarded to the Office of • I ivest ations ofthe bIA for insurance coverage verification. - _ _ fife hereby certify under the pains.and penalties ofper ray that the informdtwnprovulet tru andr ct. — __.. Signature: "i�<.--e-%-- -X ,c_/ Date: ..26 M.A )•-O 1/ • — Phone #: /g' " ' E -- / .. .-- , Official use only. Do not write in this area, to be co f}' � 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 E Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : L✓' L ), rJ 13 4.44 I License Number 7/ 6B/ 2 dof:1)1,4ny7 lea 0106 o o a(9 Y6 Address Expiration Date Signature Telephone —as /, ja c » J S 6 ' 9/ 7 8:`Rglisteietl lettgr6tet 1�` n : jt . j Not Applicable ❑ Company Name / Registration Number Addrre k �.s .,..� .F4-2/1P7 Expiration Date / 4.4-/ 16 /3 )71/ 0 Telephone v 6 0j6) - SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)} Workers Compensation Insurance affid it must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buil ng 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 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 ❑ Replacement Windows Alteration(s) ❑ Roo ng ❑ Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding Other [O] Brief of Proposed _ j I Alteration of existing bedroom Yes / No ` Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6 If . t r " -- aline :tiff iili faftit tiFt lc it ied8ili l e' ail bra: 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. Wifl 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 B ILDING PERMIT A LE ,-- x)4 / /, A ,u / , as Owner of the subject property here y 7E ie. to on auth my e alf in all matters relative to work authorized by this building permit application. Signature of Ow Date 0 M 4 6 D 1 PJ 1 � 75k X 6 , as (Authorized Agent hereby declare that the statements and information the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. iv; (V L g /? %f C Print Name � __ J �C )14A)/ a.O 1) ignature of (irJAgent Date r _ Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To incomplete Inf r * Existing Proposed Required by Zoning ' st Thiwolumn' be filled in by , Bui lding`bbpartment .— ...,_. ___._.._w Lot Size L J ' 1 Frontage I i Setbacks Front = [= , Side L:? I R:;.. i L:i I R: ! a Rear i a Building Height {--- 1 1 ` i Bldg. Square Footage "` I 1% 1 1 i f . Open Space Footage , % ? f • I (Lot area minus bldg & paved i d i ? parking) # of Parking Spaces -- Fill: , �,..,v �._ . l E________ (volume & Location) ,t, A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 t IF YES, date issued:1 IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES 0 1 I IF YES: enter Book P age 1 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 0 Obtained ,Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0 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 O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. a 1 ��� 2g 201.-, ity •f Northampton - 4t fi A : ild g Department • - N t� e 1 Main Street i:4 . , anti,* .0.01, ' •om 100 , a sow— DE ��� "�� o rthampton, MA 01060 , b ,- ` k " . � , 0 1„ 2 9 ,-. , 3a i phone 413- 587 -1240 Fax 413- 587 -1272 ' - " ' , 2 ° - a 8®_�' � > APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: ) er This section to be completed by! office L X / MO' T6 13 A to r Map Lot Unit Ai ( j - N p.,A,A Yr f T(5 � � r Zone Overlay District 010( Elm St ©tstrtct CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 7 l� G r ) N e (Print) Current Mailing Address: • Telephone i Signature 4 3° c) J '° 6 0 7 e { 2.2 Authorized Agent: f j ( Lf' )�,,' N L TS R4 '37 /' /8, 'i - 40 /6 4( Aloi ll\A77.° 1'4 Name P ' t) Current Mailing Address: `—'0 J S -- y16 7 Signature J Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building /y �^ a= (a) Building Permit Fee 2. Electrical J � (b) Estimated Total Cost of ----- Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection if, 6. Total = (1 + 2 + 3 + 4 + 5) 1y 8 g , o� Check Number )- ' ° \ 1 55 This Section For Official Use Only Date Building Permit Number: Issued Signature: Building Commissioner /Inspector of Buildings Date 1 LEXINGTON AVE BP-2011-0982 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30A - 039 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: vinyl siding BUILDING PERMIT Permit # BP- 2011 -0982 Project # JS- 2011- 001605 Est. Cost: $14885.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: B & R SIDING 026846 Lot Size(sq. ft.): 12588.84 Owner: MANN ALEXIA Zoning: URB(100)/ Applicant: B & R SIDING AT: 1 LEXINGTON AVE Applicant Address: Phone: Insurance: 781 Bridge Rd. (413) 586 -4167 Workers Compensation NORTHAMPTONMA01060 ISSUED ON:5/27/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL VINYL SIDING 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 5/27/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner