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36-074 • 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 No rthampton 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 inspectioxtproceysreguires 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 - con t thebuilding _permit,issued,_and_ 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 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. Address of work location The Commonwealth of Massachusetts a Department of Industrial Accidents -�=4i W , ' Office of Investigations � 600 Washington Street ' r =°= _ = Boston, MA 02111 � ' . www.mass.g ov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Mf'K k...1\ !J Address: �■ d k b ` Cit /State/Zip: AS4nf in1 \ VAN A 4 V 0 Phone. #: 4t -- la s - lOgqck Are you an employer? Check the appropriate box: Type of project (required): i 1. El I am a e Io er with 4.. 0 I am a general contractor and I y 6. ❑ New construction employees (full and/or part-time).* have hired the sub- contractors 2 I am a sole proprietor or partner- listed on the attached sheet 7. y I emodeJ7ng ship and have. no loyees These sub - contractors have 8. Dennolon to ees`and - have workers' working for me in any capacity. Y 9. Q Buildin addition [No workers' comp. insurance comp. insurance. required.] 5. 0 We are a corpo ration and its l OElectrical repairs or additions o ers ave xezcised. iz_ —i1. 1?lumbi - repairs or additions 3. ( I aro a- homeowner -ti v I work Q ? eP myself [No workers' comp. right 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 required. }. *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit .indicating they are doing all work and then hire outside contractors 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 not those 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 formation. 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 under Section of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to 51 and/or one -year imprisonment, as well as civil penalties in the form of a STOP W. ORK ORDER and a fine of up to $250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do her _ ' der the pains and penalties of perjury :that the information provide _ail r ve_is_true.and_correct ___ ■��—... St .0 -tore: l� q 1 s ate: ,4 • Phone ##: Al 1,Z.0 -- l� °A. - — Official use only. Do not i in this be completed by city or town officiaL City or Town: •- Permit/License #__ Issuing Authority (circle one): I. Board of Ffealth 2. Building Department 3, CitviTown Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other . Contact Person: Phone #: o , SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Constructio , Supervisor: kA Not Applicable ❑ 'ATL Name of License Holder : �(� 1�.� "' , CS 114-31 3' License Num r �.o,© 1:3\ �ti�n `t��, o���� 4 10 AA Expiration D to Signature Telephone 9.- ,Registered Home Impro ement.Cnntrac?orr... _. .,, i . i , . .,,, �, ;. ., ,. Not Applicable ❑ \& c t &AA 5 «s .4,,� IIVal Corm anv Name Registr tion Number ' Addr s Ex iratio Da e \A �,V 'N� 6k ;�v p Telephone SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6» Workers Compensation Insurance affidavit be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi 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 1083.5.1. 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 Employccs 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 ___ _ t —r —,, - - . . a-General- Laws- Annotated. nrt amptAn r tnances, a e .n.- . • - -. • . .� .. I " . Homeowner Signature r % SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House Addition ❑ Replacement W" ows Alteration(s) Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition L New Signs [D] Decks [0 Siding Dic Other [G] Brief Desc iptiprj, f ro sed 1L S t��r'1 t" Unt'4143C j "3- f9\ t40064 '�tsl h'0 \ r� "` 'w`'- ork: 1 Alteration of existing bedroom Yes t/ No Adding new bedroom Yes No Attached Narrative . Renovating unfinished basement Yes o' No Plans Attached Roll - Sheet 6a, if New'i table an r.additiOn.to, `xisf ng complete -tl a following: 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 !1 \ S - � - I, a_.�J+ � � , as Owner of the subject property \'\pr ` _ hereby authorize 1.ii'ptu to act on my beh in all . tters rela • - • work : uthorized by this building permit app 'cation. • Sign�r. --�of owner Date ' I, RkE_ cC.-' `C t 4 as Owner /Authorized Agent hereby declare that the statements and nformation on the foregoing a•.li -tion are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. ' 44 ccti c+VWe Print Name .�. . pia Si t e of Owner /Agent Date f t t 1 Section 4. ZONING Alt 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 - _.. __._ Setbacks Front " W Side L : : _ . _ — R..,_-_ _.. °. L._ R: _._. -.... r Rear _ Building Height Bldg. Square Footage _ - % € " i Open Space Footage cm (Lot area minus bldg & paved u ., a pang) # of Parking Spaces _ - -° ---. _< _ Fill: °a h (volume & Location) .. ,. .... ___ . A. Has a Special Permit /Variance /Findin ver been issued for /on the site? NO 0 DONT KNOW YES IF YES, date issued: 1 IF YES: Was the permit recorded at the Regi of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book } ? Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO e{ ONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained EP , Date Issued: C. Do any signs exist on the property? YES elf NO IF YES, describe size, type and location: 2 ) X 4 Q0tA ' C\-1(-Xs t Sk "`° D - — Are tthereany proposed changes to a rtions of signs into id d for - het property ? YES 0 NO IF YES, describe size, type and location: E. W+fl the construction activity disturb (clearing, grading, exca ion, 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. f City of Northampton S ��� ' Y ' Building Department �I; aver art f, a .. 212 Main Street Se-veq e�A'ya �mu y . 7W 1� , r± T r -, _ \ 6. -' J Room 100 ° 1 44 i4 e' a ?5 n 0 Northampton, MA 01060 � pia.,.. �" phone 4'3- 5871240 Fax 413- 587 -1272 e . � k� A v �� 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: `` '� __ \\ 1 1 ; i "�� OY�O Map Lot Unit \ 01.irz_144,, �Wr ® b '�, Zone Overlay District EJth St'District CB District SECTION 2 -PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: kt S ch(1 Name (Print) / Current Mailing Addr s ., k Ali, S /� /' i Telephone b O re 2.2 Authorized Agent: .,"•,,,. •_� Current Mailing Address: '. 4\4 — \Z .c- beck`\ \o,.4,rkN(L Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Offic Use Only completed by permit applicant 1. Building %' loco (a) Building Permit Fee 2. Electrical t _ , b0C) (b) Estimated Total Cost of L - Construction from (6) 3. Plumbing • , G Build Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 24 COD 6. Total = (1 + 2 + 3 + 4 + 5) � C heck Number ��� �S�! This Section Fnr C)ffiriaF tJSe Only Building Permit Number: Issued: Date Signature: Building i Commissioner/Inspector of Buildings Date I -- File # BP- 2010 -0241 APPLICANT /CONTACT PERSON MARK LANDY ADDRESS /PHONE P 0 BOX 61 ASHFIELD (413) 625 -6999 0 PROPERTY LOCATION 383 WESTHAMPTON RD MAP 36 PARCEL 074 001 ZONE SR(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 �� C? „tt�� /� /. _ Fee Paid S! 7” j Typeof Construction: RENOVATE KITCHEN & BATH, REPLACE SIDING & WINDOWS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 077431 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INI 9RMATION 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 I L/ J4U,r,1/4 F -c 7 Signature of Building •,i' cial 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. • 383 WESTHAMPTON RD ' ' '= - �� & ; BP-2010-0241 GIS #: COM MONWEA LTH QF MASSACHUSETT Map:Block: 36 - 074 CITY OF Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE.; GUARANTY FUND (MGL c.142A) 13uir Category: renovation iN V 31 ERiT Permit # BP- 2010 -0241 Project # JS- 2010 - 000233" Est. Cost: $24000.00 Fee: $144.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: , :. L Use Group: MARK LANDY ".- 077431 Lot Size(sq. ft.): 54798.48 Owner: SCHRADER JACOB Zoning: SR(100) //WSP II Applicant: MARK LANDY AT: 383 WESTHAMPTON RD Applicant Address: Phone: Insurance P 0 BOX 61 (413) 625 -6999 0 A S H F I E L G `:', ',401330-0061 ISSUED ON: :9/9/2009.0:00: 00 TO PERFORM THE FOLLOWING WORK RENO'4VATE KITCHEN & BATH : EPLACE SIDING& WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THExiSTRE Inspector of Plumbing Inspector of Wiring DAP'!' Bu Inspe Underground: Service: / C � - � Rou h��- -r� � : ° � _ - Footings � F. - Rough: r '' g �- H Foundation ° � ` � l' Vl Drlvitra� Final: Final: ,ti� Final :i. 3C -CS y 2 . _ .. ,,,, a elil l '/-0 � Qugh Frame: Bl !d G Gas: Fire Department =F: ,7-7,÷7.--We plce /Glumney: I; rrabh: 1 "`., ` ` i,.• I. f � g '� .� it: I�t ._ -- ,,, Final: j2 - I Smoke: t2�'L4 / _ a F :{. _.__.�% THIS PERMIT MAY BE REVOKED BY THE'C113' OF NORTHAMPTON UPON VIOLATIQ O ANY OF ITS RULES AND I GULA'�'IONS } _ ,w; , , Certificate of Occupanc . '''-`4'.« t A liz at 4 � � A „oa s t! ..." FeeType: Date r Building ..9/9/2009 0 00 :00 , $1 4�L o t ,- , ",km. . 2 Main Street Phone ' '1'4' ' » 12 40 Fax: (413) 5 87 - 1272 ~ Building Comm s onyx' , All,. thony Patillo "