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31A-295 (4) 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 jermits 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 opfassachusetts --7--fr--.4-- Department of Industfial Accidents - Alt __E:-...r•-z-- fi, Office of Investigations . 600 Washington Street 1,Bif a Boston, MA 02111 -_ - , www.mass.gov/dia • _., -Workers' Compensation Insurance Affidavit Builders/Contractors/Electhcian.s/Plumbers Applicant Information - Please Print Legiblv Name misinessiOrgamzationfIndividuaI) 2 r . C.., - Address: 3 z- .."'S F ,A V---).... City/State/Zip: I Tk\f\ct.Vv--1)+c Phone.#: ?i3 2-ig z1 Are you an employer? Check the appropriate box: • Type of project (required): 17 • 1. 0 I am a employer with 4. 0 I am a general contractor and I • 6. E] New construction employees (full and/or part-tim.e).* have hired the sub-contractors listed on the attached sheet 7. 0 Remodeling 2.112 I am a sole proprietor or partner- These sub-contractors have • ship and have no e.,loyees •8. 0 Demolition working n:giloyees_andhive workers' _. _ king for me in any pacity ca. 9 0 Build asIdition _ compt.insurance_f__ _ • ___ _ _ _ [No workers' comp. insurance requirecLJ 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 txercised their . 11.0 Plumbing repairs or additions myself [No workers' comp. Hen of exemption per MGL 12.0 Roof repairs . - insurance required.] t • c. 152, § 1(4), and we have no • . employees. [No workers' 13.0 Other • • comp. insurance recpnred.j *Any applicant-that checks box #1 must also fill out the section below showing their workers' compensation policy infonnation. t Homeowners who submit this affidavit indicathig they an doing all work and then hire outside contractors must submit anew affidavit indicathag such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractcns and state whether-or not those entities have employe. If the sub-contractorshave employeee, they must provide their woriners' comp. policy number. - I am an employer that is providing workers' compensation insurance for my einployees. Below is the policy and job site informtrtion. . 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 policy number and expiration date). .__ Failure to secure coverage . as required tinder Sectiiiii'25A c 152 can lead to the ifiipOsitiini of Critainaj 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-0_17.DM and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of InVestizationi &the DIA for iniurance Cove verification. _. . ... „ , _ , ,,, _,_ . I do hereby,certzfir under tkpainsand penaldes ofperjury that the &for:natio' n prwvidedabovr_ e_rold_corre Siat rt __ gnure : / . ___________ , • — D ate 1 1 6 ' — ' . . Phone it: . - Official use only. Do not write in this area, to be completed by city or townOfficiaL • City or Town: Permit/License # Issuing Authority (circle one): .- ' _ _ :1. Board of Health 2. Building Department 3. City/Town Clerk .4. ElectricalInspector 5. Plumbing Inspector 6. Other Contact Person: ' Phone #: k-• . . • SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: ( Not Applicable ❑ � Name of License Holder : r r \ L ` G `' � 4 6 4442--) License Number , fk k V--a- 1.(z t3 Address Expiration D Da Signature Telephone 9.;R tilstei eiiaHt�ri a mpi �retrfent Conti c or =.. . _ Ki . .; linigaizakESIt Not Applicable ❑ T c 164-iaat Company Name Registrati n Number t (1 � Address Expiration Da e 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 ❑ The current exemption for "homeowners" was extended to include Owner - occupied Dwellines 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 R." SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition El New Signs [O] Decks [p Siding [0] Other [0] Brief Description of Proposed L - Work: r &. • 'D t e t. � os,, x � G — r t o P to►S e-/ t t f • S l a .( S.> — . Kct..) rc too Alteration of existing bedroom Yes No Adding new bedroom Yes )K No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa Ne a and $a dIi lo'n t e ti ci.ho iiii:aii ifikatieltartiiiiiiiiii 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 g rthd. k - Vkt t t 1, , as Owner of the subject property n hereby authorize ' V \ 4` v "` to act o behalf, in III matters relativ to w r]c autho • ed by this building permit applicati n. .!_ ' � LL- c \ 1 c . i Signature of Owner Date 1, si \ Tam V `�' - , as Owner /Authorized Agent hereby declare that the statem is 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. E V 1 (.- T C"v13 1"-SL— Print Name ]" 2 1 0 Signature of Owner /Agent ' 0. e 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 %7 Building Department Lot Size i 1 ! . .-.- - ... • Frontage r i I i - Setbacks Front t j 1 - 1 Side L:.J R: i 1 L: 1 R:1 1 1 - -..._ ? x d , i Rear Building Height = = € Bldg. Square Footage Open Space Footage @ s % (Lot area minus bldg &paved i , _ J 1 parking) # of Parking Spaces Fill: �.,..�... --- � ,�.�, . . ..�... �. �..��, (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO @ 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 P agel , and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 .9 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained 0 , Date Issued C. Do any signs exist on the property? YES ® NO 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 IF YES, describe size, type and location: 1 E. WIII 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. - „- - irr ‘F I SPITATISC,.4,": 'atja',;1L- tRP City of Northampton „,)* ,k...4.1.& ... Building Department 4 \ Wi ' iiik 1 al• , , # 01\‘ \ \ 212 Main Street Room 100 „r;P;tzfiw,....10sr77773777:7N 'iit - . , \ ' i it -..°";:, ' - '- 7 7 , 17,4 7 7: 6 0,7 , 1`74. z .= ' - •W ''-* ''' ' Northampton, MA 01060 ,/ XZ41:k1500:1;:i .,,,,,,,,,,,,-,-; `,,,II,:l..:....;.t :41..;,(5.:144,,Zigiitc:- phone 413-587-1240 Fax 413-587 P lr:,,!tpk'4kt-,':-l--,;rr7-aAt3:'"V"::g7''7' , \ .2—i,AZI:gi - 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: eiS_c=. \,) e....,, Ni\c. v., Map Lot Unit k ) 0 v - \s”. k 0 \r■ , , -, Overlay District eim st District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ,C , ,\. (-t---- f Name ri 7 \ ) r , Current Mailing Address: 1 ....._ g.(0 ,,.__ 70 9 g , ... (-e-r- ( - - - s - j-7 Telephon t i ' \ 1)L C CA- } u-L Signatur \ en 2.2 Authorized Aoent: 32 l 3Ork5 A PI E r i c...- Pa. \A vve.--• Name (Print) Current Mailing Address: 1 - 7C0 Telephone elephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 7, (:),C5e2 (a) Building Permit Fee (b) Estimated Total Cost of 2. Electrical 2, l o 0 C. Construction from (6) t 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection .--- ci 6 0 6. Total = (1 + 2 + 3 + 4 + 5) t Clied Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Date Building CommissionedirlsPector of Buildings File # BP- 2011 -0596 APPLICANT /CONTACT PERSON ERIC PAYNE ADDRESS /PHONE 32 BURTS PIT RD NORTHAMPTON (413) 218 -4276 () PROPERTY LOCATION 86 VERNON ST MAP 31A PARCEL 295 001 ZONE URB(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 Tvpeof Construction: REMODEL BEDROOM (SHEETROCK,INSULATE & NEW FLOOR)) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 086442 A .� �V�dC( (‚ (A i'� 3 sets of Plans / Plot Plan M a 5T f N = ! A C t E `� � c a nd ( y THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9R'MATION 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 Building Official Date Signature of u g 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. BP- 2011 -0596 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 -0596 Project # JS-2011-000960 Est. Cost: $9600.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ERIC PAYNE 086442 Lot Size(sq. ft.): 5314.32 Owner: PHILIPS BRENDA J Zoning: URB(100)/ Applicant: ERIC PAYNE AT: 86 VERNON ST Applicant Address: Phone: Insurance: 32 BURTS PIT RD (413) 218 -4276 0 N O RTHAM PTO N MA01060 ISSUED ON:1/4/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: REMODEL BEDROOM (SHEETROCK,INSULATE & NEW FLOOR)) - MUST INSTALL CODE COMPLIANT SMOKE & CO DET 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 1/4/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner