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31C-002 (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 L h h ome " v.. c... oti�i' d iet. 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 regulation The insI)e ' n n �ce�a re - wir e s that the building department be calle 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 - _----- _-- - - - - -- pits- in- conjunction_to- the- buildirig-pern3itissued,- 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 wner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents • . Office of Investigations ' 600 Washington Street Boston, MA 02111 www.mm gov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumb.ers Applicant Information Please Print Legibly Name ( Business /Organization/In&vidual): Address: City /State/Zip: Phone. #: Are you an employer?. Check the appropriate box: Type of project (required):, 1. Q I am a employer with 4.. Q I am a general contractor and I 6. Q New construction employees (full and/or part time). *�'e hired the s'.i -rout actcrs 2. Q I am a sole proprietor or partner- listed on the attached sheet. 7. F Remodeling ship and have no e.- iployees These sub - contractors have. .g. Q Demolition working . for me in an ca employees and have workers' Y capacity. 9. Q Budding addition [No workers' comp. insuranc comp. insurance.T required:] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions — 11 cers�a yPTr t ir .-Q-Plumbiag repairs or additions 3.0 T- am- a-homeowaer Being allweFk , myself [No workers' comp. right of exemption per MGL 12. [],Roof repairs insuran required] t c. 152, §1(4), and we have no employees. [No workers' 13.Q Other coxop. insurance required.} `Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy info rnation. t Homeowners who submit this affidavit.indicating they are doing all work and then hire outside contractors roust submit a new affidavit indicating such. &Contractors that check this box must.attached an additional sheet showing the narne of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy nurnber. lam an employer that isproviding workers' compensation insurance for my employee& Below is thepolicy andjob site _formation. _ Insurance Company Name: Policy # or Self-ins. Lic. #: Expiration Date: Job Site Addre City /Stafe/Zip: Attach a copy of the workers' compensation poli cy declaration page (showing the policy number and expiration date). Failure to secure coverage as required. under Section 25A of MGL c. 1 T52 can lead to the imposition of crimin4l penalties of a fine tip to $1,500.00 and/or one =year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a finne of up to $250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of Investigations of the MA for insurance coverage verification _ I do hereby certify unrl gins and _ - _aloes erjury that the iirformatian provided abovE ' rue_artdcarrecL -__ _ i tore. Da , Phone #: 3 01 ; Y �2 -Official use only: Do not write in tkis area, to be comp eted by city or town ociaL _City or Town: Permit/License # Issuing Authority (circle one): - L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrica Inspector 5. Plumbing Inspector 6. Other r Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone �.. Rearstere >l�ome trrapirener.Gritractc ., nq... �,w . $. .' Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone S ECTION 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...... ❑ on _ _The-current-exemption for "homeowners" was ext ended 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 referencerto 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 responsib' ' or liance with the State Building Code, City of o amp on r tnances, a e n ' httsetts E'reneral Laws-Annotated. Homeowner Signature a SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House Addition Replacement Windows Alteration(s) �_ Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding [p) Other [O] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes ( No Attached Narrative Renovating unfinished basement — Yeso Plans Attached Roll - Sheet tia �4rf� `Ne��r�ISe��ai>�d���acldi€�a�� t��r ��lsti�rg�- h�usrr�iioinislet� .ttr�:fc���o�urri±�: 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 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, as Owner /Authorized Agent hereby declare that the statements 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. P' Name ooe Sig of Own 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 Lot Size Frontage -J Setbacks Front Rear Building Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg & paved # of Parking Spaces (volume Location) A. Has aSpecial Permit/\ahance/ Finding ever been issuedfor/on the site? �� �� �� NO %�� DDNTKNOYY �_� YES �_� IF YES, date issued: IF YES: Was the permit recorded at the Reg of Deeds? NO �_ K � - DON7 KNOW .-- IF YES: enter Book and/or Document# B. Does the site contain a brook, body cf water orwetlands? NO 0 DDNT KNOW 0 YES 0 IF YES, has permit been or need to be obtained from the Conservation Commission? Needs tobeobtained �� ���in� �� ����d' — —� �~� 'L_-__-_-- ' C. Du any signs exist on the property? YES 0 NO x~~\ ! ����—�--------------------------------- IF YES, describe size, type and location: ( .... .... ...... ... .... ........ ______ .... ......... _____________�_/ ~'^ p YES �� _� NO x�� x�� � |F YES, describe size, type and location: E. WiUthe construction activity disturb (clearing, grading, excavation, er filling) over 1 acre orisd part ofo common plan that will disturb over 1acre? YES� � NO �l �� �� IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ` City of Northampton w7 g Building Department���� 212 Main Street ..x Room 100 Northampton, MA 01060 phone 413- 587 -1240 Fax 413 - 587 -1272 t� 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 �r UWA 4vfN _)E Map Lot Unit / 0 C) Q1_ yfFAvTaN oO 14- Zane ' Overlay District 0( O6 © Elm St; District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: - S''-'` - - -'_ - - - - - -- - - - - -- - - -- `' _► 1n/ 1f1��Y'17.1/ Name (Print) Current ailing Ad 0 Telephone Signat 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - :ESTIMATED CONSTRUCTION'COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building A(/ (a) Building Permit Fee ' 2. Electrical / 0 (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) Check Number This Section For Officia['Use Oitf Date Building Permit Number. Issued: Signature: Building Commissioner /Inspector of Buildings Date BP- 2010 -1130 GIS #: C OMMONWEALTH OF MASSACHUSETTS :31C -'002 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- 2010 -1130 Project # JS- 2010- 001658 Est. Cost: $1800.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 50529.60 Owner: BRUMBAUGH SAMUEL & GALAXY CRAZE Zoning: RR(72) /URA(28) //WP Applicant. BRUMBAUGH SAMUEL & GALAXY CRAZE AT. 48 WARD AVE Applicant Address: Phone: Insurance: 48 WARD AVE (413) 586 -0472 (� NORTHAMPTONMA01060 ISSUED ON :611112010 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL FIREPLACE INSERT 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 6/11/2010 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo