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29-407 (2) �e � � �` '� �, �� �� ... ,�. ,. "� ..� w J _._._._..____.._�_._w.._,.__v.,___.�_�___.__. _.___,_. -__.__.___ ��., __... � .___.� � _. _ �. _. � � _. �S Sf�k --- __- �..._--- i I I ����I 1 f �� � a t � � r� � �j ,�! 3'XY� � u �0 �r`t�1— � 9 1 � S '; : � I � ��/ _� ���� � t ____� _�.{ v _�. —._..._� ,���� ---.....r.�,�� ..—.w..._... f ---__ . - �� � ��r �i � �: �., r G w.. r 3 2,v !' _ f iass aC411setts DEPARTMENT OF BUILDL\NG INSPECTIONS + =/ INSPECTOR 212 Main Street • Municipal BuiIduiv Northampton,MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act aS l.is/her construction sup­: ::'Sor. The stare 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 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 back--fill). sonotube holes (before pour). a rough building inspection(before work is concealed).insulation inspection (if required) and a_final_buildina 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 occupancv 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 VA, 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. y Date Address of work location ? The Commonwealth of 11AIassachusetts Department of In dustrial Accidents �' O,jfice of Investigations 600 Washington Street Boston,M4 02111 www.mass.gov/dia Wormers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information LL _ Please Print Legibly Name(Business/Organization/Individual): 1L}� 6' f LAC Ah 0-- Address: La►vt Illy . City/State/Zip: 00 P R_4 n e.e U 61W Phone.#: C4 f Are you an employer?Check the appropriate box: Type of project(required): m a genera contractor an 1. 4. � I a l t d I I am a employer with New construction employees(full and/or part-time).* have hired the sub-contractors 6. 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet 7. Remodeling ship and have no employees These sub-contractors have S. Demolition working for me in any capacity. employees and have workers' [No workers' comp,insurance comp. insurance.: 9. Building addition 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 I L Plumbing repairs or additions myself. [No workers'comp. right of exemption per 1VIGL 12. Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp,insurance required.] 'xny app tcan that checks oox i;l a=also 1111 out the section below showing their workers'co npensation policy inforaation. 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 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 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 for-warded to the Office of Investigations of the DLA for insurance coverage verification. id ahereby certify under a pat and penalties o perjury that the information provided abo a is true and correct - SiQnafure` — ---- — — Date: 0 j� Phone#: vjjxzai use only. Do not write in this area, to be completed by city or town gT7ciaz City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone T: SECTIONS-CONSTRUCTION>SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9andarsteied EC ome.-frri6t&V6iri Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10=WORKERS'COMPENSATI ON.INSURANCEAFFIDAVIT(u;,G.L..c:f52,f25C(0)) 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-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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House [� Addition ❑ Replacement Windows Alteration(s) Q Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [I]] Decks [M Siding[lam] Otherj] Brief Description of Proposed Work: Pn Alt_e ra-t i o_n of existing be dr ocm Yes No -Adding newtedroom V Yes No Attached Narrative Renovating unfinished basement Yes _—No Plans Attached Roll -Sheet 6a 4f kiorrs attc[a ai ditiQi .ta:exlst� lc tous>ex�:.,.�o r�et f +�fciFtai r 4: 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 o. s cons ru ton w i 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-OWNERAlUTH-ORIZATION.-TQ BE COMPLETED=WHEbt OWNERS AGENT-OR. ' GENT QR CONTRACTOR APPLIES FOR.BUILDING PERMIT I, 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, 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 pains and penalties of perjury. Print Name �We4" 4 -��, i 7// Sign re of O n r/Age Date 'g.a* Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due ToTncomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Deparunent Lot Size Frontase Setbacks Front Side L. R L ! P. Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #ofParking Spaces Fill: i # (volume&Location) i A. Has ar � / SSpp`ecial Perm it/�V�arriance/Finding ever been issued/f�o�r/on the site? IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES 0 IF YES: enter Book Page. i and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES Q 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 O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO 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. k]eparfcrxen TE�; � •City.of Northampton Statseecm Building Department MUD -� 212 Main Street Se ep[t _°A'a�ta l x� Room 100afe, tcelfEr�a�lab�s m " Northampton, MA 01060ucsSets of SfracluraPfans �" z phone 413-587-1240 Fax 413-587-1272 PtaSrfe f'Ians �' QtherSpecaf - - APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION.1 -SITE INFO - RMi4t10N. -..• ___. c Thi- sectrortta be compCeted byaf. 1.1 Property Address? --- _ San m l( >=,a unto - � , � D (�v//���i I / Zuite c .erfapDrsf�c I�I Pr t 1 a t _. Eft�StE Distryc> CBDistrtct SECTION 2 PROPERTY OWNERSHIPIA.y:1THORtZEDnAGEUT a 2.1 Owner of Record: Nrelco�S� � 3-C N,R N044 Name(P n t) Current Mailing Address: _�j/L - Telephone Sig ature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-E!§tMATEQCONSTRUGTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building i�( ODD 00 _(.g.Building,:Permit Fee 2. Electrical I ry tip�j _(by Estimated Total Cost-of S W Construction:.from(6) 3. Plumbing �VwO0 Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) QQ� Cl heck Number This Section For Official Usa Only - Building.PermitNumber Issued: Signature: Building Commissioner/Inspector of Buildings Date "tife04 BP-2008-0304 '-0y.•;�� APPLICANT/CONTACT PERSON CZAPOROWSKI STEFAN ADDRESS/PHONE 81 SANDY HILL RD FLORENCE (413)586-8634 Q PROPERTY LOCATION 81 SANDY HILL RD MAP 29 PARCEL 407 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OJIT Fee Paid Building Permit Filled out 4,40 Aft, Fee Paid Typeof Construction: FINISJj BASEMENT(BEDRM,FULL BATH,OPEN/STORAGE AREA)_ New Construction Non Structural interior renovations Addition to Existing^ Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF1291ATION 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 Street Commissio /�c ee L 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. 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