Loading...
35-046 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 pxoQess 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- the.building permitissued, 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 me. sec Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents I _''l l•-= ri Office of Investigations • ,� 600 Washington Street g Boston, MA 02111 y� ' www.massgov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers Applicant Information 6 \ k 11W Please Print Legibly Name ( Business /Organiiation/Individual): C3 Address: €.-- -- S\ 2 l CA. s Sk) City /State/Zip: ( QINc v ru-� Phone.: S c � q (...,---1 Are ou an employer? Check the appro 'ate box: Type of project (required): / 1. jJ I am a employer with 1 4. ❑ I am a general contractor and I 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. ❑ Remodeling ship and have no a Io3•ees These sub - contractors have. 8. 0 D.emoution capacity. employees and have workers' working for me in any P ty 9. ❑ Building addition [No workers' comp. insurance comp- insurance.: re aired 5. We are a corporation and its 10.0 Electrical repairs or additions required.] ce _have- xercis their 1-1, • - ,9 ,ig ; 3.❑ J am a homeowner deiaB ali wck o _.__ -- — ❑ g repairs or additions myself No workers' comp. righ of exemption per MGL 12. P 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 #I- 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 subcontractors have employees, they must. provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employee. Below is the policy and job site formation. Insurance C o m p a n y Name:: l . 1 - t C/. /-4- r}■,/ - Policy # or Self-Ms. Lic. #: © 0 N I L( 1 V % eQ 0 Expiration Date: 3 f in " (:)C `" \ 1 Job Site Address: q ( S � t ( - A ' -�C ,d 1,N y - -t.,., e l k City /State/Zip: ` 01. C) 6 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 fine of up to $250.00 a day against the violator: 'lle advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certify under the pains and penalties of perjury that the information. provided _aboveeislrue.aruicarrect~_ _ . '.W l it � Date. 0 _ Si�.. ture _ Phone #: Official use only. Do not write i this. area, to be completed by city or town ofciaL City or Town: Permit/License # Issuing Authority (circle one): - - 1.-Board of Health 2. Building Department 3. City/Town -Clerk 4. Electrical Inspector 5. Plumbing Inspector _ _ _ .. 6. Other r Contact Person: Phone #: .r' SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : — 711 b CO S (O 9 9 License Number _ coq l-k Co • �� • t Address Expiration Date Signature Telephone 9..-Reoisteretl klori3e. tm ro em "e "iit Gtatttractor .: »,.., .„..., Not Applicable ❑ js Company Name Registration Number 9.4 I • Address Expiration Date y �_ 'W Telephone 5 �� — 1 (".0 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 buil ing permit. Signed Affidavit Attached Yes No ❑ fix x £ W e' a Q .13flOn The_current 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 and assumes responsibility for compliance with the State Building Code, City of o ampton finances, a e and - M } to i _ .' . s eneral- 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 El New Signs [0] Decks [[l Siding [0] Other [0] Brief Description of Proposed A Work: . i► >v � p� _:e `•-le Tinkr Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa: If New<house`and `Orradditioiko<eicistinghousitkv&tnOlete the 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? 1. 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 r l I, I , ° , as Owner of the subject property hereby authorize (- ) N) &-) to act on my behalf, in all matttsrelative td work authorized by this building permit application. 0 \ 0 Signature of .' ner Date 1, • a. A s • , 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 paine and penalties of perjury. R —: tt;A t r-- tb Print Name Signature of wner /Agent Date R d 4 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 _._ __ ... _ _ µ ,.__. Frontage Setbacks Front Side L:— ......— R::,„___.: L: R _ ._. . Rear Building Height Bldg. Square Footage % Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces ---• - -... Fill: (volume & Location) .---- -m° - -- ----- ----.. ----- A. Has a Special Permit /Variance /Finding ever been 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 Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Pagel i and /or Document It, F µµ ~Y 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 0 Obtained , Date Issued C. Do any signs exist on the preperty? YES 0 NO 0 IF YES, describe size, type and location: f - -- -- D: a Are there n si ose�dlan es to or adtions o ' sgns ntended f r the property YES 0 NO 0 2 YP P >; 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. City of Northampton Building Department Citt)rt�r z r 212 Main Street 100 � l u w� e4 . g Northampton, MA 01060 � } o r ins 0 a phone 413 - 587 -1240 Fax 413 -587 -1272 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 Map Llif:.,/ 3 0 2010 Unit 6 n Zone Overlay District EI St_Distrlct CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: t - -- �� - Y _nom ct �; � Rt-t A n g_ 4 Name (Print) Current Mailing Address: t.. (() t - v Q-k A r L r _ ,�� - _ V Telephone Signature /` 2.2 • thorized Agent: y ' ` n Q _ Name (Print) Current Mailing Address: -ter Sa � ? 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 Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 35 5. Fire Protection 1 6. Total- (1+2 +3 + + 5) 1 Check Number t This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building Commissioner /Inspector of Buildings Date BP- 2011 -0505 GIS #: COMMONWEALTH OF MASSACHUSETTS 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- 2011 -0505 Project # JS- 2011- 000827 Est. Cost: $1685.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BOB THIBODO ROOFING & SIDING 065699 Lot Size(sq. ft.): 24654.96 Owner: PRONOWITZ ELLNISE D & DANIELLE R GUEYDAN Zoning: SR(100) //WSP II Applicant: BOB THIBODO ROOFING & SIDING AT: 965 RYAN RD Applicant Address: Phone: Insurance: P 0 BOX 201 (413) 527 -7663 0 WC NORTHAMPTONMA01061 ISSUED ON:12/1/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL NEW RUBBER 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 12/1/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner