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32A-198 t _ 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 paces& 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.xhe- building permitissued,_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. Dates _.. Address of work location . • - The Commonwealth of Massachusetts Department of Industrial Accidents } " i� P Office of Investigations • k .'� # 600 Washin Street Boston, MA 02111 .� . ' www.massgov /dia -Workers' Compensation Insurance davit: Builders / Contractors /Electricians/PIumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City /State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): -I' 1.0 I am a e Io er with 4. 0 I am a general contractor and I Y have hired the sub- contractors 6. ❑New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship' and have no. eu loyees These sub - contractors have 8. ❑ Demolition worldng for me in an capacity. employees and have workers' Y ca P ac tY 9 u Bmicdi Y addition [No workers' comp. insurance comp. ;nsutattce.# required. 5. 0 We are a corporation and its 10.0 Electrical repairs or additions re q ] o cers_lavexxercised_their_ L1- P--lumbm 3.y1 I- am- a�omee�+aer-dem work - - -- _ - - -- �- g 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. [No workers' 13.0 Other cone. insurance required.] *My applicant that checks box #1 must also fin out the section below showing their workers' compensation policy infomnation. I 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 information. 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 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine 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 Th of up to $ 250.00 a day against the violator. 13e advised that a copy of this statement may forwarded to the Office of Investx ations of the DIA fo insurance coverage verification I do herebyfy �;;;• /yI f e pains and penalties ofperjury that the information provided _ above is true.and_correc�_ - Date: O ., 0 Phone - I S J j `� r C �2 ' ^Official use only. Do not write area, to be completed by city or town official _ , City or Town: Permit/License # Issuing Authority (circle m ne): I: Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical I • . ector 5. Plumbing Ins. ector 6. Other _ . 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 9.; Register ee3 ::HorrerlenprnueerttGoirtractor` .. ... ,.,_. ` . ,._....'.` y Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone _ SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) J 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 ❑ onie nJ - l *ion 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 a . a es r ..onsibility for compliance with the State Building Code, City of o ampton et' tnances ' a e :• , ` • _ f ° • • • - • s-Gener - a1- Laws - Annotated. Homeowner Signature C / / — . tiQ i r- • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing n Or Doors E Accessory Bldg. ❑ Demolition ❑ New Signs [p) Decks [El Siding [0] Other [�jj Brief Description of Proposed -.- ` �tl Work: ►?g // � r //7- 6 5 IC7/Z- - e/r 7 tv CA/c!, Alteration of existing bedroom Yes .V No Adding new bedroom Yes o Attached Narrative Renovating unfinished basement Yes 1 No Plans Attached Roll - Sheet :64 if (6i - tiO lse;'artg r ad tiorlid eigkinq housing domOloteAiie 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 , 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 as Owner/ thorized Age here Y re that the statements and information on the foregoing application are true and accurate, toy knowledge and h Signed under the pains and penalties of perjury. Print ame 4 41 ignat re of ► er Date • A 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 Setbacks Front =` Side Rear Building Height �> Bldg. Square Footage i Open Space Footage _..,_ (Lot area minus bldg & paved, parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 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' and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 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 (2) NO 0 IF YES, describe size, type and location: T - D. - fie tfiere an proposed to or ad rtions o "s'i ns intended t>`ie' ro ert YES 0 NO 0 Y g P P Y? 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. . ■ Cit o f N 'qtat vf , P e � .��� '� Y a , �3 Mires � _ , Building v 212 Main Street ding Department ee y ` x , • ��e y � �� gi 5e� t epic * sail_ = ctit i .4i g 2CG9 Room 100 �� �a ��, zo , p A,L 2 0 North mpton, MA 01060 f = - i rt 7 F''_. l l i £ A t . phone 4111 -58 1240 Fax 413- 587 -1272 e't l' ` � a ` x emu 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-"-- � 1, i //), j 7/ ti (' Map Lot Unit „ ," i ,.1 . {�. ii i j,4'4 <Zoiie O verl a y D 07060 E lmSt District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: _ / h <'l9 i �Ji Name (Print) Current Mailing Address; ,. 3 /0 _4/3 5- - /'0?O . ... Telephone Signature 1 22 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 permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of o Cnstruction from. (6) 3. Plumbing . ' Building Permit Fee 4. Mechanical (HVAC) — 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number / 9 p� - This Section For Official Us Only Building Permit Number: Is sued: Signature: Building Commissioner /Inspector of Buildings - - Date 25 PHILLIPS PL BP- 2010 -0217 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A -198 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 -0217 Project # JS- 2010 - 000271 Est. Cost: Fee: 525.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 15594.48 Owner: HOFFMEISTER COLIN 70'11 ;_ ;CYI90)/ Applicant: HOFFMEISTER COLIN AT: 25 PHILLIPS PL Applicant Address: Phone: Insurance: P 0 BOX 1301 (413) 586 -8791 () NORTHAMPTONMA01061 ISSUED ON:8/26/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL PELLET STOVE 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: ev THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOL N OF ANY OF ITS RULES AND REGULA N Certificate of Occupancy Signature: FeeType: Dat• Paid: Amount: - _ Building 8/26/2009 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo