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22B-025 (2) City of Northampton !nes 4 '-- --- -Arc' r Massachusetts ,,� , � 1 DEPARTMENT OF BUILDING INSPECTIONS �� �= 212 Main Street • Municipal Building ,y ., , , Northampton, MA 01060 ` y . ,,, INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT f - , The State of Massachusetts allows the homeowner the right under 780CMR 10:. .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 ne or two family dwelling, attached or . -tached structures accessory to such use and /or farm tructures. A person who constructs m• e than one home in a two- year period shall not be considered a ome owner." The building department for the City of No ampton wants any perso ' (s) who seek to use the home owner exemption, to act as their own constru ion supervisor, to be are that by doing so you become responsible for compliance with sta building codes nd regulations. The inspection process requires that the building department be Iled to inspect. ork at various stages, which include foundation /footings (before backfill), sonotube h es (beforpour), a rough building inspection (before work is concealed), insulation inspection required) and a final building inspection. The building department requires these inspections befo thq; is concealed, failure to secure these inspections can result in failure to obtain a certifi aite of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (elect ical,plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure the) proper permits in conjunction to the building permit issued, and that they get their required inspec$ons. Failure of the individual trades to secure the permits and inspections as required can DELAY th' project until such time as the proper permits and inspections are made I, understand the above. (Home owner /resident's signature requestin exemption) I will call to schedule all required building inspectio s necessary for the building permit issued to me. Date Address of work location • e The Commonwealth of Massachusetts �-`. Department of Industrial Accidents k . Office of Investigations �. 600 Washington Street . 0 V ,� Boston, MA 02111 __ , - , www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Naive (Business /Organization/Individual): _ Address: City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. 11 I am a general contractor and I 6. ❑ ew construction employees (full and /or part- time).* have hired the sub - contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. IV Remodeling ship and have no employees These sub - contractors have 8. n Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing 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' 13.111 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. 1 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. I nsurance Company Name: 1 r olicy # or Self -ins. Lic. #: Expiration Date: i 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 fine of up to $250.00 a day against the violator. Be 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 ce 1,1 an er t pa' (a ,, penalties of perjury that the information provided above is true and correct. Signature: O if ► Date: l e 1 i 9 IN P )— Phone #: L I ( 7 / 6 , 7 IV Official use only. Do not write in this area, to be completed 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 Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: r SECTION 8 - CONSTRUCTION SERVICES 1 8.1 Licensed Construction Supervisor:. Not Applicable ❑ ( Name of License Holder : O 5 License Number 3 3 Orya 4/ .g_ (i;a i f 1g 9V Address /? Expiration Date 4 , 6 U t� Signature ;�;�/ Telephone 1 q ( 710( /0/i ii 3 9:ARe;ister HomeI i,1 v. - t` Contractor:, 17 .:- ' , _ ,,_ -, t . ;, :,-_ 117a Not Applicable ❑ r Company Name Registration Number Address S °V1r112-19/v 5 v ExpiFatiod Dafe 47 _ Telephone [ r (// 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 buildi permit. Signed Affidavit Attached Yes No b 1 1:� 1.1",- , E xe m p t ][ The current exemption for "homeowners" was exte to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual or hire who does not possess a license, provided yat the owner acts as supervisor. CMR 780, Sixth Edition Section 10: .5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intepdsio reside; on which there is, or is intended to be, a one or two family dwelling, attac -d or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home' a two -year periods—halll not be considered a homeowner. Such "homeowner " shall submit to the Building Official, on a ■rm the Building Official, that he /she shall be responsible for all such work performed under the buildi , : mit. As acting Construction Supervisor your presence •b site , '11 be required from time to time, during and upon completion of the work for which this permi -: ssued. Also be advised that with reference to apter 152 (Workers' Compen ation) and Chapter 153 (Liability of Employers to Employees for injuries not resulti. L in Death) of the Massachusetts Gen- al Laws Annotated, you may be liable for person(s) you hire to perform work for . u under this permit. The undersigned "home. , er" certifies and assumes responsibility for corn. 'ante with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massach .efts General Laws Annotated. Homeowner Signature 4 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) . New House n Addition ❑ Replacement Windows Alteration(s) n Roofing Or Doors E7 , Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [E] Siding [p] Other [ID] Brief Dew tiop of Proposed �- 44,-... _ - Work: K lat,c -2, o� ' O 'V\ VI e--- M.e. q S G CP..c.l c e- ma 4 e-r C24 d Alteration of existing bedroom Yes V No Adding new bedroom Yes ✓" No .,64 , Attached Narrative Renovating unfinished basement Yes r/ No Plans Attached Roll - Sheet s if Neuvxhous and . or addit `to: ez� hous nq, complete they follow ng : 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 —1_i e. Number of stories? f. Method of heating? Firepla = or Woodstoves Number of each ' g. Energy Conservation Compliance. , Masscheck En- :y Compliance form attached? h. Type of construction `\ i . Is construction within 100 ft. of wetlands? Yes No. Is construction within 1 6 0 - K . 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 OWNERAUTHORIZATION - TO BE COMPLETED WHEN OWNERS; AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 4 r ` �I I, / j C i 1 ' , v SQ as Owner of the subject prope r eby aut or = 5 Q � L • / o act on - alf, in all matters relativro w, authorized by this building permit f•plication. i i. na of swner r Date jj�, l I . r , 1 1 _ % A - . 7 LC k I AS Own: ^ uthorized Agen b • hereby declare that the ts and on on the foreoing ap. •� t'ccurate to the be of my and Signed under t , • Print Na ,.� r r , .._ Signature of Owner/ gent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by 'Zoning of • This column to be filled in 63% Building Department Lot Size _ _ _ _ _ Frontage A ------- - — — ----- -- Setbacks Front _ __ \ _. Side L:._..__._- L::_____;' R:..a Rear v. Building Height t l Bldg. Square Footage % �''� r Open Space Footage % ___ '\ r { — (Lot area minus bldg & paved _ $ parking) / # of Parking Spaces r` f Fill: i / I (volume & Location) - -- i l 5 A. Has a Special Permit /Variance /Finding ever been isjued for /on the site? ' ,. NO 0 DON'T KNOW 0 /YES 0 , .\ IF YES, date issued: r \\ IF YES: Was the permit recorded at the Regist of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book / Page and /or Document #! B. Does the site contain a brook, body of ter or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the prope ? YES 0 NO 0 IF YES, describe size, type a d location: : D. Are there any proposed cha es to or additions of signs intended for the property ? YES l NO Q 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. 1 � ���I V _ � ©epartmem use only f, City of No rt ham pton Status of Fe 1, Bui lding Departm Cu C ut/D nv eway Permtt � 2 12 Main Street S e w erlSepticAvari ak�l it ��,5 Room 100 1/Vater/11Uell A vailab i lity ▪ "��'- DEPT. OF BUILD IN INSPECTIONS NORTHAMP MA 01060 orthampton, MA 01060 T Se of,S f r uctural Pl ays • ° ' phone 4 13 587 -1240 Fax 413 - 587 -1 272 l' Other Si e� '1,7s'',...' �� � • '��� " Spec ify,. , APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ON O R TWO FAMILY DWELLING SECTION 1 Thi s ection to be completed by office 1.1 Property Address: SITE y� . 5 �0( , c /J• INFORMATION �/ r'4►4� Map Lot Unit F 1, d Q n - -- Q� Z o e n Overlay Distric Eim St. District C B District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: t i - -.W '1 L° / IL' 2 2 s �O 7 LL / / ' _ 5 r `�C +eG�G2 e ( P r i i f ` �� i; i �9' � ' Curren ij�ing - Signat 2.2 Authorized Ayent: `I ,(_ j �iJ� } P •K 'l oS••i � J / r- /—�,,�t / ' � Ct► Cam` �,1 / �� `� Name (Pri Cu Mailing : Rddress � Signature , Teleph rent SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost ( Dollars) to be Official Use Only . k 8/ completed by per applicant 1. Building ©� (a)" Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction fro ,(6) 3. Plumbing Building Perm 4. Mechanical (H VAC) 5. Fire Protection _ 6. To tal = (t + 2 + 3 + 4 + 5) Chec k ` Number it This Section For Official Use Only Building Permit Number: Date - Issued: Signature: Building Commissioner /Inspector of Buildings Date 25 CORTICELLI ST BP- 2013 -0547 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 22B - 025 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP- 2013 -0547 Project # JS- 2013- 000883 Est. Cost: $8000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 11064.24 Owner: AIKEN CHRISTOPHER Zoning: URB(100)/ Applicant: AIKEN CHRISTOPHER AT: 25 CORTICELLI ST Applicant Address: Phone: Insurance: 25 CORTICELLI ST (610) 425 -7672 0 FLORENCE ,MA01062 ISSUED ON:11/13/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE WITH METAL 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 11/13/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner