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23D-004 (2) • 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 • • .O f NI- •t •- ••, •rocess 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 pits-in-conjunction-to-the_huilding-permitissued,_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 'me as the proper permits and inspections are made `�yq4Q`r understand the above. (Home owner/reside s signature requesting exemption) I will call to schedule required building inspections necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts �, Department of Industrial Accidents --.E.-_--„tirW.P Office of Investigations _ �_ 600 Washington Street cr j Boston,MA 02111 www.massgov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Apnlicant Information t Please Print Legibly Name (Business/Organization/Individual): it 4,RN Address: 1. 341( U City/State/Zip: ki\, ,t4LA t Mi r&>1130 . Phone#: 40- iN Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New constriction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. f Remodeling ship and have no employees These sub-contractors have. 8. X]Demolition working for me in any capacity. employees and have workers' 9. u-Buddiag addition ,ns ce.. [No workers'comp.insurance cow i required] 5. X We are a corporation and its 10.0 Electrical repairs or additions 3.0 3 am-a hemeowne ioing-all--work- -- -- _---o -lave'xezcised their _ ❑Plumbing r epairs or additions myself.[No workers'comp. right of exemption per MGL 12.0.Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.i2 Other Cs rt1'�Sl comp.insurance required] 66` *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. TContractors 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. 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 wader Section 25A of MGL c. 152 can lead 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 fine of up to$250.00 a day against the violator. Ike 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_above istrueiznd.correct-__ P.•tire 'N IWAI V&A i NNM■MMMMMMMNMMMIMIMMIIIMIMIMIIIIIP. Phone#: �'` 3:2-'51 i 1 i - Official use on Do not write in this area,to be completed by city or town official Ci y or Town: Permit/License# 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#: - SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: \AfttilL Vikwdt C5 ..4141-41 License Number b1 MA a 01330 -4)114 Address Expira Date 443 — 62c—LgetzC Signattre Telephone 9.,Rectisten:i_,Home lm br'ovementGio~tractor ,, a Not Applicable ❑ ikA ct \-Aft DAsk 7)ymL S1 a;3i 111bT7 Company Name Registr tion Number 1)tbi 1,‘ ti)(141 Address p Expiration Date � � \t"1�a lr 1.3343 Telephone 11-S"lDg ` 1 — 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 ❑ /.mtliorernerm: 11 on 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 1083.5.1. Definition of Homeowner:Person(s)who own a parcel ofland 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/ 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 amptoh•r•ltlances, i . e • i • • • 1 •- ,. .' •-"v. --a v #.• °s- raiLaws-Annotated.• Homeowner Signature //7"4-‘- SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ �{ Or Doors El Accessory Bldg. El Demolition L�1 New Signs [0] Decks [D Siding[el Other[D] '‘tG 1r f2 4u+1 At4401 N loktivri Iofck {tto Brief Description of Propose Work: C-An+. tsc S Q tAlAi 1►141X a fl 1t4 011► 6't�''lieaa /ZtY!" Nt° a La�►�va-� Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ✓ No Attached Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roll -Sheet if New-hotiae:,ant or.additi t to°existing'housiiiq;>:lcoinp(ete_tie foifowinq: 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!"' 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 4: e s as Owner of the subject property hereby authorize 1,4 1 to act on my behalf, in all matters relatwork authorized by this building permit application. Signature of Owner Date \,A A( ..43e4 , as C ¢ler/Authorized Agent hereby declare that a statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. MileA 1.004=11 %A. kANAA c to 14 Signatur ofdw ec/Agent Dat- 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 iab� Building Department` }.' i ro waw. Lot Size '` Frontage Setbacks Front " , Side L._....,_.,. R. ___....w /L.:_.. ....:. R.. .._____ t' Rear ..µ.. , Building Height Bldg.Square Footage 7--- I ' o%a r - 1. Open Space Footage _——i (Lot area minus bldg&paved parking) #of Parking Spaces _ --- _,... ._ _ Fill: r—._ . —11 _ __ (volume&Location) ---.--._ ,_.._.�... ._.__,._.. ..,__ A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW ei YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW (3 YES 0 IF YES: enter Book j Page: and/or Document# r.B. Does the site contain a brook, body of water or wetlands? NO 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 property? YES 0 NO (3 IF YES, describe size, type and location 'D:-Are there any proposedcianges o ora ittons o _stgt intendedfoit1i property? YES 0 NO IF YES, describe size, type and location: ^ E. Will the construction activity disturb(clearing,grading,ex ion,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 WaterManagement Permit from the DPW is required. RECEIVED t��7 ® ®a� itortly� �b a •'ty of Northampton tasolF`� rt � � ; B ilding Department 3 ZQ13 212 Main Street Room 100 o hampton, MA 01060 e ��� � � ten OF BUILDlNG 'PECTIO *'� N13- 87-1240 Fax 413-587-1272 NORTHAMPTON f3+ 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 t <�_r_ Map Lot Unit fl C3 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record:14-, Name(Print) Current Mailing Address: Se } Telephone J Signat re 5/ f — s- 2.2 Authorized Agent: MArk LANA.y IA<.`tcx bi PtsWWW.ntbt VO, LSj,330 Name(Print) Current Mailing Address: 4i3 - b L - 6111 Signatu Telephone SECT! N 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 3 c.O Q (a)Building Permit Fee 2. Electrical ..tea (b)Estimated Total Cost of Construction from16) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) vo Cfaeck Number Gov 1 This Section For lifietal Use Only Building Permit Number: Date - _ Issued: Signature: Building Commissionertlnspector:of Buildings-" Date File#BP-2013-1088 APPLICANT/CONTACT PERSON MARK LANDY ADDRESS/PHONE P 0 BOX 61 ASHFIELD (413)625-6999 0 PROPERTY LOCATION 15 NONOTUCK ST MAP 23D PARCEL 004 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid i06219- I/37c Typeof Construction: REPAIR ROTTED WOOD,PORCH,WINDOW,BULKHEAD 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFQ NIATION 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 Air 1,7p . 0. r 64/- SI /3 Signature of Building Official 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. 15 NONOTUCK ST BP-2013-1088 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23D-004 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2013-1088 Project# JS-2013-001793 Est. Cost: $3500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK LANDY 077431 Lot Size(sq. ft.): 5270.76 Owner: SHALLCROSS DORIS J TRUSTEE Zoning:URB(100)/ Applicant: MARK LANDY AT: 15 NONOTUCK ST Applicant Address: Phone: Insurance: P O BOX 61 (413) 625-6999 () AS H F I E L D MA01330-0061 ISSUED ON:5/14/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIR ROTTED WOOD, PORCH, WINDOW, BULKHEAD 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 5/14/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner