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32A-240 (3) . 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 proceys,�reggi ires that the building department be called to inspect work at various stages, which include foundation /footings (before backfhl), 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 – _ - - - - -- ---per ts_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 understand the above. (Home owner /resident's signature re ting exemption) I will call to schedule all required bui inspections necessary for the building permit issued to me. Date— Address of work location The Commonwealth of Massachusetts V ■ Department of Industrial Accidents =UIrar P Office of Investigations �[.f 19 600 Washington Street _ [ f Boston, MA 02111 , ' ■ � . www /dia Workers' Compen.sation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LegibIv Name ( Business /Organization/Individual): fi( Address: \ IaO ( o\ City /State /Zip: ikSlortkOa l W\ $ 6 CC3 ® Phone. #: 4 - iT-S- bi i Are you an employer? Check the appropriate box: •Type of project (required): l 1. ❑ I am a employer with 4. D I am a general contractor and I mployees (full and/or part-time).* have hired the sub- contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling hip and have no loyees These sub - contractors have. 8. emoi on for me in any capacity. employees "andhave workers' working Y P ty. 9. Q Butldi g addition [No workers' comp. insurance comP..:nsurance_# required.] 5. 0 We are a corporation and its 10.0 ElecrricaI repairs or additions 3. 0 I" am a -homeowner- doing- all - work — o cers_have xer_cise_d heir —I-1- Q- Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 121of repairs c. 152 insurance required.] t ' §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance requited.} *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' corm. policy number. /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 of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1 and/or one :year imprisonment, as well as civil penalties in the form of a STOP WORK 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 h - , .. ° {c der the pains and penatras of perjury that the information provided_ ' 0 ve_ true _andcorrect ___ __ 'oar Si. a . tare: � ' s ate- `i® ( Phone #: 4 .— VIC 619 O use o Do n ot w in th a to b 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 I. - • ector 5. Plumbin _ Ins • ector 6. Other r Contact Person: Phone #: , SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: 1 :: _ ot Not Applicable ❑ Name of License Holder : 1'L 1 tJ 1'1-431 License Nu e 4- ilio Exp to .. 4Vc L7 S Ls4g r Signatur- Telephone 8.. Registered Home hritirait°" e_triCContract r .. E. .,, 24.:.. , s ,.g.. , , ..... ,, , !- Not Applicable ❑ V PA 1-451•KS 1 Company Name Registra 'on umber Pttox. ? 1b tb Addy s ` -� 1 /� *� 11 oo Expiratio D ,ca. o��v) Telephon€1C " \AC) _ SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit st be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the build' permit. Signed Affidavit Attached Yes No ❑ 11 ..BIo r r r ni Ihe_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" m. _, ,_ _,_.., certifies and assumes responsibility for compliance with the State Building Code, City of — 'oil amp on •relnances, a e - 0 • K4 • , 1 ,, .. i • . - s- Genoral-Laws- Annotated. Homeowner Signature ../Qt< r SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House Addition ❑ 'Replacement Wi ws Alteration(s) Roofing ❑ Or Doors Accessory Bldg. El Demolition New Signs [0] ' ecks [[] Siding [0] Other [0] �? "� ' 1...414.1...411...414.4.. I• Brief Description f Propos vE144.1? `� 41i' 1 ' S 17 C - 54 2 1 13 K ' k 43 � t t �' + r j 4 ' Work: � id( %1 11 \ �l - t+3N 4 �q►I '� +7CZ� 4 p.� x � Alteration of existing bedroom ` Yes No Adding new bedroom Yes v No _......-- Attached Narrative Renovating unfinished basement Yes ,___%, No Plans Attached Roll - Sheet 6a. IfWNe*. . and - or. addition to; existiriq tiousinek"COInplete- th 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? V OPC 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 o r ii" ( s Owner f the subject propert /1i r . , i ' , hereby a oriz- _% - to act on r'. •ehalf, in matters -lat�, o wo a thorized by this building/ rmit application. ed .- r ., attire of ` Date 1 , '` ( © &Wirt A /K , as Owner /Authorized Age ereby declare that the statements and informatio • n the foregoing application al% true and accurate, to the best of my knowledge and belief. it Sign'-* • •der the pains and penalties of •erjury 9 rah* 0 f( Vvt4t(t.....4 Print N ; 1 / -� Q � 1. „ S 1 Si• ature of Owner /Agent Date CEIIIIIIIIIIIIBil • 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 L ., __ R. _ __mm R: Rear Building Height Bldg. Square Footage [ % Open Space Footage (Lot area minus bldg & paved „ , parking) # of Parking Spaces Fill: (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: IF YES: Was the permit recorded at the Regi ry of Deeds? NO 0 DONT KNOW YES IF YES: enter Book Page a or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Iss d: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: '! D. - Are tie any proposed Ehahges to or adaftions ofsilns intended for tire property ? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, ex tion, 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. a4e, o01 City of Northampton Statics tO Building Department C ll m E# v w 212 Main Street S ., # bil l - Room 100 ��� '� r m - r; Ui) Northampton, MA 01060 T „r - z -p 413- 587 -1240 Fax 413 - 587 -1272 " ISiki i ite E- i 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: 10R liif1 &At c5112.5/. 5 /. Map Lot Unit N ay f � t Zone Overlay District EIrmSt District CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Recor (I'D Name �,ikNE ,lO(c��1 __...------- -- - -- - -- _ - tog' is, .__ - v‘r t %OENN 1�w IAA, 0\c 1.b Name (017. C Mailing Ad _ / — Telephone �� ':natu e 2.2 A horized AgeM 4 ( k Lftt‘l(S r 1O .7,0 lel 'QVIINkkkA i l'Afk (2•16 a ±�. , Current Mailing Address: 4t3 —1;2S - 15Vici Signature Telephone SECTIO - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building W / 1 a t ‘00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of . Construction from (6) 3. Plumbing • �,..%, Building Permit Fee 4. Mechanical (HVAC) `-- 5. Fire Protection - a v 6. Total = (1 + 2 + 3 + 4 + 5) Q� Check Number / s i' This Section F6r't)ffiaiafUse drily Date Building Permit Number: 'Issued: Signature: Building ICommissioner/Inspector of-Buildings– Date I - File # BP- 2010 -0256 APPLICANT /CONTACT PERSON MARK LANDY ADDRESS /PHONE P 0 BOX 61 ASHFIELD (413) 625 -6999 0 PROPERTY LOCATION 109 BRIDGE ST MAP 32A PARCEL 240 001 ZONE SC(8)/URC(92)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid 7(6 S Typeof Construction: REPAIR CABINETS, COUNTERS ,FLOORS,DOORS,WINDOWS,PORCHES 7 NEW PORCH ROOF 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 FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 ,72.4 Signature of Building 'facial 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. • T BP- 2010 -0256 GIS #: COMMONWEALTH OF MASSACHUSETTS ..; V 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 -0256 Proiect # JS- 2010- 000325 Est. Cost: $12500.00 Fee: $75.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK LANDY 077431 Lot Size(sq. ft.): 9713.88 Owner: TODRIN DIANE K Zoning: SC(8)/URC(92)/ Applicant: MARK LANDY AT: 109 BRIDGE ST Applicant Address: Phone: Insurance: P 0 BOX 61 (413) 625 -6999 () ASHFI ELDMA01330 -0061 ISSUED ON:9/9/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: REPAI R CABINETS, COUNTERS ,FLOORS,DOORS,WINDOWS,PORCHESeI NEW PORCH ROOF 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 9/9/2009 0:00:00 $75.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo