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29-188 (2) �O� . �`� zl '��'zTxl &11rtDrYr S 3 +iassac4uscffs t tl Ini DEPF RTMENT OF BUILDLjG INSPECTIONS INSPECTOR 212 Main Street • Municipal Building Northampton,MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as 1.1s/her construction sul :, 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 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 backfill). sonotube holes (before pour). a rough building inspection(before work is concealed).insulation inspection (if required) and a_final_buildipa inspection. The building department requires these inspections before the works 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 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. y Date Address of work location r" `, tie �4'- \ • ♦ 'a y The Commonwealth of ltilassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, M4 02111 www.mass gov/dia Workers' Coml)ensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Informarion Please Print Legibly Nalne(Business/Or,- n ition/Individual) M!L 6-c I T-;�I Y eo o q Address: 0 9 I"c7 ery f�'J 2�9 U« , '� City/State/Zip: 50—�r�gk -7 14411Z 020_?? Phone.#: ��3 -S� ;7— ��� Are you an employer? Cheek the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 7 I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.9,I am a sole proprietor or partner- listed on the attached sheet_ 7. ❑Remodeling ship and have no e doy ees These sub-contractors have S. Demolition working for me in ax:y capacity. employees and have workers' [No workers' comp.insurance comp.insurance.t 9. Building addition required.] 5. 7 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 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.g�Other C ✓A/I 4�0 12� rpki comp.insurance required] ----- xny app icon a c ec oox Gust a o n out_ a section ow showing their wo cott�ensation.policy-infor¢ation. - Homeowners who subtrat 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 mus:.attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-connactors.ha re employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:__-�?JP/(i _ Policy#or Self-ins. Lic.#: !o 2 Z U 6 —08a,C.C?y—K^D 7 Expiration Date: Job Site Address: f 1'f 2J;(y,e,r K e42 .�2,i2 City/State/zip: uc Z2W 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$1500.00 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 Iie violator. Be advised that a copy of this statement may be forwarded to the Office of Investizations of the DLA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. S-ianatnre a - - --- - �"2f- 7 Date: Phone#: yL 7 `,7—' 2,K� — Luse only. Do not write in this area, to be completed by city or town ggzleiaL Town: PermiUicense# Authority(circle one): of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Person: Phone 4: �r „ r ♦ er t SECTION 8-CONSTRUCTION SERVICES' 8.1 Licensed Construction Supervisor: Not Applicable El Name of License Holder:Iiory y 00 7, &'Ac ),00 C� ic" ' -7 00q License Number Address Expiration Date --!�D 0`1L tom► 0a Signature Telephone 9 Rei e°sfered Fla a Trs tirciueinent Ca teac€o -44 A0 .; Not A hcable PP i ❑ 7o Company Name Registration Number Address Expiration Date Telephone SECTION 10 WORKERS'COMPENSAkTION INSURANCEAFEIDAVCT(KG L-c-152,.&;25C(fi).). 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...... ❑ aer I = yfl > 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,von may be Gable 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 La State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ AddiJon ❑ Replacement Windows Alterations) �7ftofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[C7J Other[O] Brief Description of Proposed R, /�l c Work: i dl/l VV_kC4 Alteration of existing dedircom__Yes No - Adding new-bedroom Yes No Attached Narrative Renovating unfinished basement Yes —No Plans Attached Roll -Sheet say!�-[Vev��toil5e�a�r�i3 o�a€�drt>ran��f��x%st�n€�-�o rsii��.-�oAtefe���'�a�tov�ir�g: 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 iew 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 roc n wr i es-- - No j. Depth of basement or cellar f cor below finished grade k. Will building conform to the Euiiding and Zoning regulations? Yes No. 1. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTEIOF RATION-T0 BE°COMPL'ETED-.—W. HEN OWNERS AGENT-OR,CONTRAGTORAPPLIES F0F;,9E1lCDlNG i?ERMIT as Owner of the subject property / hereby authorize �l�f/( to act on my beha!, in all matters relative#o work a thorized by this building permit application. /,/)"2'e� ,A A-M- —-?-1 0 Si a ore of Owner Date I, (l.{?(47 'A' j � � as Owner/Authorized Ag nt 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/. ,57E' Prinl Name Signature of Owner/Age Date f ♦ r► ,wdt 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 Deparanent Lot Size - — Frontage Setbacks Front -Side L. - R L: RR Rear Building Height Bldg.Square Footage % Open Space Footage % Clot area minus bide&paved parking) #of Parking Spaces Fill: (volume&Locadon) s A. Has a Special Permit/Variance/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 0 DONT KNOW © YES 0 IF YES: enter Book Page: and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES O 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 Q 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 0 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. -� Qelrarfrnenerse only a City of Northampton StatrsaEerrn t RR Buiiding Department > n�ew� . n X212 Main Street 5ewer/SeptlAVai7alrclrt { - _ Room 100 V9 feWC bdifivE M= X07 Northampton, MA 01060 rcrsetsolstracEerral Plans '_ 2 phone 413-5871240 Fax 413-587-1272 PtosEfePlans - PP)1ICSbtTIO�11tQ,m�;ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION1,-SITE INFORMATION This sectrorrta 6e completed`6yoifct 1.1 Property Address: N,,�tapw i=ot Eicu'1 - f I ESt Distrrct SECTION`2-PROPERTY`OWNERSHIPf,4UTHORIZED,'AGENT 2.1 Owner of Record: Name(P nt) Current Mailing Address: P Telephone `� 5 "y n ure 2.2 Authorized Agent: Name(Print) Current Mailing Address: UP q/?- 2 Signature Telephone SECTION 3-EST'INIATEFt:CONSTRUG- TION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building V 0 0-Building,,Perm it Fee 2. Electrical (by'Estimated Totat.Cost_of Construction-from.(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section-ForOffic al'Use Only - Building Permit Number. Issued: Signature: Building Commissioner/Inspector of Buildings Date BP-2008-0328 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-2008-0328 Project# JS-2008-000468 Est. Cost: $3200.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin MICHAEL MCKENNA 132070 Lot Size(sq. ft.): 18469.44 Owner: DRAGON WALTER S&EMILY C Zoning: URA Applicant: MICHAEL MCKENNA AT. 142 DEERFIELD DR Applicant Address: Phone: Insurance: 209 POMEROY MEADOW RD (413) 527-1266 SOUTHAMPTONMA01073 ISSUED ON:912512007 0:00:00 TO PERFORM THE FOLLOWING WORK:RE PA R CH I M N E 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 9/25/2007 0:00:00 $25.002844 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo