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32C-338 A 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 backfilf 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 ., 1 T The Commonwealth of Massachusetts ,.— Department of A - p ;� — _ _ � Office of Investigations . +�� y 600 Washington Street . Boston, MA 02III �4rc" . www.mass.gov/dia . -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information - Please Print Legibly :� Name ( Business /Organiaation/Individ - e G °• 4 e t a i'• el i f i' ' c i' d" • Address: /' /` 4` �4"/1f t/ 2 /,y L-41 , City /State/Zip,o , / %9. a `' -7• Phone. #: V/ ,7 Z- I% 7/ Are you an employer? Check the appropriate box • Type of project (required): / 1. ❑ I am a loyer 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.. Q I ani a sole proprietor or partner- listed . on the sheet. 7. ❑ Remodeling . These sub-ccontractors have ship and have no employees 8. 0 Demolition working for me man employees andbave workers' Y capacity. 9 $till alldition [No workers' • comps iosurancC — CoRip. mcr7ranrr. #_ re �edj 5. a are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers havepercised their 11.0 Plumbing repairs or additions . myself [No workers' comp. Hen of exemption per MGL 12.0 Roof repairs c. 152, 1 and we have no insurance required :1 t 4 e s ) v' 13 ._.�� r: ! employees: [No workers' ✓' . comp. insurance required.j. • *Any applicant-that checks box #1. most,also MI out the section blow showing their workers' compensation policy information t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submita new affidavit mdic anng such. - :Contsacturs that check this box must attached an addtional sheet showing the name of the sub-contractors and state whether ornotthoseentities have employees. if the sub - contractors have employees, they must provide their workers' comp. . policy number. • . - Iam an employer that isproviding workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: . • Policy # or ins. Lic. #: Expiration Date: Job Site Address: City /Stafe/Zip:' - • Attach a copy of the workers ' compensation policy declaration page (showing the policy nand:Her and expiration date). Failure to secure covera ge. as required imder.Sechnn 25A: oflGlCrL c: 152 can lead to the imp`osrtiim`of c 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 - ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of taus statement may forwarded to the-Office of rnvestiiations of the DtA for'insuranee coverate verficatron. :7,,.....7,, I do hereby_ certi niter the pains and penalties ofperjury that the information providedsrbo aaricorrert - -- _ . Signature: 'Noe - .�.. -r Dat y l. ` 1, Phone #: 19 7 . .. Official use only. Do not write in this area, to be completed by city or townoffu:aL City or Town: Permft/Lfcense # Issuing Authority (circle one): .'1. Board of Health 2. Building Department 3. City/Town Clerk . 4. Electrical,Inspector 5. PIumbing Inspector 6.Other Contact Person: Phone #: • t SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License Holder :77 c:- f 9 f�© .1/ft Z �? License Number Address Expiration Expiration Date C",1 /t7 �. j / VI , f i Signature C � Telephone Not Applicable ❑ '�. a.�. - '. tom. S 1__ °' n. `..��..233" ^i e 1 �. ®.ci!.$ ®fit" - :�°' ����"� ...a - � � :�... = pp Company Name Registration Number ffe 4 : 36 74 , 4`; Address Expiration Date 4_, Telephone 9/ j -7/ 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 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 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 4 , SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) E3 Roofing E Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [I=1] Decks [[] Siding 01 - Other [0] Brief Description of Proposed Work: 7—', % e1 t , ,.a., .lr,°c�e / 49 7.7 !tr /e <As? Alteration of existing bedroom Yes 'No Adding new bedroom Yes l/ No Attached Narrative Renovating unfinished basement Yes '" No Plans Attached Roll - Sheet sa s . vide". . ,iii 'I alw i. pstrif it 'mu lir a: 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 . 1. Septic Tank City Sewer Private well City water Supply SECTION Ta - 'OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 1\ ->z I G •c , as Owner of the subject property �\ hereb authorize >✓4'' CA«aC to o behalf, II tters relative to work authorized by this building permit application. Signature of Owner Date I, / tip'' C l �', �� , as Owner /Authorized Agent hereby that the stafements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Si ned under the pains and penalties of perjury. Print Name yl / Signature of Owner /Agent a. Date , , , . ,,,, . /e lf , , , , 1 b Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To 1 1 plete'Informatto Existing P oposed Re • ed Zo , Th1 be fille.. by Buildin , t Lot Size ; . Frontage 11. r, Setbacks Front I s 1 Side L:' F R:i L' R:' , . .'.._.f.. , Rear 1 Building Height d ) Bldg. Square Footage = 1 1% 1 1, I 1 1 1 E s Open Space Footage I % • (Lot area minus bldg & paved i 1 parking) 3 # of Parking Spaces = I 9 2 Fill: 1 I . (volume & Location) N I 1 A. Has a Special Permit /Variance /Finding ever b n issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:{ IF YES: Was the permit recorded at the Registry of eeds? NO 0 DONT KNOW 0 YES 0 I IF YES: enter Book i P ge i and /or Document # s B. Does the site contain a brook, body of water or wetl nds? NO 0 DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained rom the Conservation Commission? Needs to be obtained 0 Obtained Q ,Date Issued: C. Do any signs exist on the property? YES ® NO 0 .._. IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0 IF YES, describe size, type and location: 1 ' E. Will the construction activity disturb (clearing, grading, ex. - vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES (2) NO 0 IF YES, then a Northampton Storm Water Management P. rmit from the DPW is required. ter �l i1 o ortham ton µ ,epartment r W .� Y - in Street �� J r..v,- oom 100 • g k • ampton, MA 01060 � ''13- 587 -1240 Fax 413 -587 -1272 AP ON 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: �,I ��'•' /✓�T. .Map Lot Unit Zone Overlay District Eint St. District ` CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: '.n Current Mailing Address: Te lep h one y Signature 2.2 Authorized Agent: r ^ ti 4 L. 4.--o4 ; �E C S S`�: /l - "J'" ,A je,-,/ Name (Print Current Mailing Address: 4 f/ 4/e 7J / 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 i 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection ro 6. Total = (1 + 2 + 3 + 4 + 5) Check Number , This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 12 HENRY ST BP -2011 -0885 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C - 338 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: vinyl siding BUILDING PERMIT Permit # BP- 2011 -0885 Project # JS- 2011- 001443 Est. Cost: $3500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DAVID CHICOINE 061582 Lot Size(sq. ft.): Owner: GRACE ADRIAN M & DEREK FOWLES Zoning: Applicant: DAVID CHICOINE AT: 12 HENRY ST Applicant Address: Phone: Insurance: 16 EDGE HILL PLACE (413) 246 -7536 AM H E RSTMA01002 ISSUED ON: 5/2/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE WOOD SIDING 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: FeeTvp Date Paid: Amount: Building 5/2/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner