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24D-236 (3) ' # I a:sacimsctis �' a ,,,,n- - DEPARTMENT OF BUILDING INSPECTIONS � INSP�CTCR 212 Main Street • Municipal Building r — Northampton, MA 01060 \'— '� HOME OWNER ER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as ;pis /her construction sup .- sor_ 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 d welling, 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 any 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 backfill). sonotube holes (before pour). a rough building inspection (before work is concealed). insulation insnection (if reauired) and _afnaLbuilydinginspection. 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 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 me. Date Address of work location • 4.fN, The Commonwealth of lIassachuse rs T ,Department of Industrial _4 ccidents l Office ce of Investigations 1 T� j 600 ashin� on Street ^^,-'' r' Boston, ALI 02111 j ,.:- . 15,' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers AD D11cant Information Please Print Legibly Name (B- siness/OrganizanonilndividuaI): WINDOW WORLD- - - - 56 Dimock Street - Address. Leeds, MA 01010 CIty /State/Zip: 5! ' ! • one . Are you an employer? Check the appropriate box: Type of project (required): 4. I am a QeneraI contractor and I 1. ❑ I am a employer with ❑ 6. Q New construction . e Ioyees (foil and/or part- time).* have hired the sub- contractors r 1 listed on the =ached ghee Q R emodei ing l i I � am a sore proprietor or partner - These sub - conctors have Demolition ship and have no employ es 8. 0 Demolauon 1 working- for me in any capacity. employees and have workers' 9_ Q Building addition [No workers' cow: a"li su ante comp. insurance.'- required.] 5. Q e are a corpora*on and its 10.❑ Elect ica repairs or additions 3. ❑ I am a homeowner doing all work oEcers have exercised their 1 I_Q Pltnnbins repairs or additions myself o worn :s' caxnn. rift of exemption per MGL 12. Q Roof repair insurance required ] t c. 152, §1(4), and we have no 13.0 Other employees. [No workers' comp. insurance required.] -- ---"` iiy appucant mat C.2=1Z oox r1 angst aso IIll out me sermon oeiow snowing their wor s' compensation policy mformarion. t Homeowners who submit this affidavit indicative they are doing all work and then bi: a outside contractors must submit a new affidavit indicating such. Conc- actors that check this box must-ararhed an additional sheet showing the name of the sub-contractors and state whether or not those entities have e:npioyees. If the sub - contactors, have employees, they rruLst provide their workers' comp. policy flambe Iam 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 Se rion 25A of MGL c. 152 can Iead to the imposition of criminal 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 one 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. 1 do hereby ceri fy under the pains and penalties of perjury that the inforrnarion provided above is true and correct. --- Stsuatu mss 1-.;=- - - -'� D ate: /U /6 !J 7 Pho e ' Y 7/Z- -- 1 II Official use only. Do not wrzte in this area, to be completed by cizi or town offzciaL City or Town: Per-mit'License Issuing Authority (circle one): 1. Board of Health 2. Building Department City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other I Contact Person: Phone .. -: r WINDOW WORLD 56 Dimook St Leeds, MA 01053 30 4... Telephone 5884712 CONTRACT Date tit Thi agreertlent botween e Chtwer) and f • odaftto WINDOW '** V lie :RLD OF LEEDS, AlASSACIIUSE S. Pi ne S1' li'f:"11‘14..'ATIC)NS • e , .. . . _ !lott2rs 70'i) or Olt- t1 coutx,xt tiet it ptr „ability io obtain ' ghol! Afl c'ier par Lo cr4C 2 r , ttr on the 4g!, , t ort,iftiul) w ncut.iccur _ , .1 CrwrIer SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor Not Applicable ❑ /4monde) Company Name Registration Number WINDOW WORLD ?` /a e Address 56 Dimock Street Expi ation ate Leeds, MA 01053 586 8712 Telephone — 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 ❑ 11. — Home Owner Exemption 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 -vear 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 Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature S SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House n Addition ❑ Replacement Wind Alteration(s) ❑ Roofing n Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [D] Other [D] Brief Description of Proposed -_. Work: _4- & Sr 4/4- Luc_ • cf Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete 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? 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 I, _ `_ S ( , as Owner uthorized) hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my an`d �ielief. Signed under the pains and penalties of perjury. Print Mme Signature Owner Age .o7 Dat � Section 4. ZONING Alt lnformation Must Be Completed. Permit Can Be Denied Due To tncomplete lnformation Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size -----'-------- - ---------'---- ---------------- Frontage ---------�---- ------ -- -- - -- '-'---- -- Setbacks Front „--- ' --- Side Rear Building Heigh ---- �---. ---- Bldg. Square Footage „ �� Open Space Footage __ m ___ __ r-- (Lot area minus bldg & paved _nmmo� # of Parking Spaces �--- ---- ---- Fill: -----'-- ------��---- ----�-�-��— --����- (volume a Location) A. Nas a Specta[ Permit/Variance/Finding ever been issued for/on the site? 0 0 �� NO \~� DONT KNOW \~� YES \~� IF YES, date issued: `----------- IF YES: Was the permit recorded at the Registry of Deeds? NO 0 ) DONTKNOYY 0 YE5 0 IF YES: enter Book Page � and/or Document# ------` ---- ----- '--------` - �� B. Does the site contain a brook, body of water or wet[ands? NO \~ �� / DONT KNOW \_/ YES \� �� � IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained /�� Obtained Date \_� ~ , Issued: / _� C. Do any signs exist on the property? YES \ NO \~ /_� � IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YES, describe size, type and location: E WIU the construction activity disturb ring, gradingexcavation, or filling) over l acre orisKpart ofa common plan that will disturb over 1 acre? YES ) NO (� ) �� �� |F YES, l6en Northampton Storm Water MdnagehTehfPennit from the DPW is required ti Department use only City of Northampton Status of Permit: `, Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/WeII Availability Northampton, MA 01060 Two Sets of Structural Plans phone 41,3 -58 1240 Fax 413 - 587 -1272 Plot/Site Plans Other Specify APBLtC,ATI{?N TO C RUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SEkT SITE INFORMATION This section to be completed by office 1.1 Property Address: Map Lot Unit Zone Overlay District / i t rro 51)Ct T - _57 Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: yduil 1--v � � L �.- /1 5' Iic: siiee % , <Jcv � <<, 2, Name (Print) Current Mailing Address: • Telephone Signature 2.2 Authorized Agent: �� c ►� r— as t "c6 ad i / h9 a C./4- s ' I c t c: s1 evio -5 Name ( Current Mailing Address: Print J � X 7, �. S. ture 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) • 5. Fire Protection 5) /CJ /�i r.hark Nnmher e 1 0 Tidal -(1 i�igi 4 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector ofBuildmgs Date ` BP- 2008 -0430 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- 2008 -0430 Project # JS- 2008 - 000634 Est. Cost: $4015.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: John Corbett 104000 Lot Size(sq. ft.): 10715.76 Owner: LOVELL KRYSTYNA Zoning: URB Applicant: John Corbett AT: 194 PROSPECT ST Applicant Address: Phone: Insurance: 56 Dimock St (413) 586 -8712 LEEDSMA01053 ISSUED ON:10/23/2007 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS 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 10/23/2007 0:00:00 $25.002705 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo