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29-214 (3) F Ira* r Lzfy o arf4a111Vtzn �.. � �a3sac3�usetfs <1 1 DEPARTMENT OF BUILDI3,,7G INSPECTIONS /- 212 Main Street • Munic;i a1 Building INSPECTOR p Bu / � °� s<•` Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CNlR 108.3.4 to act aS :is/her construction sups.: .-:-,or. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two fanuly 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 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 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. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ADDlicant Information. Piease Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone.#: 7Are you an employer? Check the appropriate box: Type of project(required): 1.Q I am a employer with 4. Q I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.9I am a sole proprietor or partner- listed on the attached sheet. 7. Q Remodeling ship and have no employees These sub-contractors have $. Q Demolition working or me in an capacity. employees and have workers' g Y P t3'• 9. ❑Building addition [No workers' comp.insurance comp. insurance.$ required.] 5. Q We are a corporation and its 10.❑Electrical repairs or additions 3.Q I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.7 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.Q Other comp.insurance required.] ------*Any app t'can� a c ec ox must a o r out a section ow 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. *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 employee& 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 S 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 5250.00 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 certify under the R„tl ui a ties of perjury that the information provided above is true and correct. Signatur Date: S Ph #: vffcciai use only. uo not write in this area,to be completed by city or town offrciaL City 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: AL' ' jameej ! License Number LAO ©u K S 'f�t�c� 1^14. eiQS-- A z' log Address -7 Expiration Dite doll l'cl aturg Telephone 9-RegrMered dome lmpro3ement-Corantctor Not Applicable ❑ Company Name Registration Number Address Expir tion D to 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.�rxner-ExtgAiAbn 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) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[0] Other[El Brief Des tion of Proposed Work:_Y GCE Skv +ah{� Alteration of exi$tirig bedroom Yes V Adding new-bedroom Yes No Attached Narrative Renovating unfinished basement Yes �- �No Plans Attached Roll -Sheet ouse.an -�adtl m fof.lowingsa.1New° t : 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 construction within 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 I, C IiZa�0 V1 ��� ,as Owner of the subject property /� (�,� herebyauthorize �eSse ,A" m44owe' " � to act on my behalf, in all afters relative to w&A authoriz y this building permit application. Sign tur of Owner Date T- I, azC1(,, '+k cl as Owner/Authorized Agent hereby declare that the staterdents and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under trrhe pains and penalties of perjury. 11 w be',,�� Den h AJ P t Name 'n i ature of Owner/Agent D to J a 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 Department e- Lot Size — Frontage Setbacks Front -Side L:-. R: L: - R Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&pave, parkine r--- #of Parking Spaces Fill: i (volume&Location) A. Has a/S�p\ecial Perm it/Variance/Findin er been issued foorr/on the site? IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? 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 NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearin ,grading,/exvation,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 Water Management Permit from the DPW is required. Depatfinent:usa oni} City of Northampton Status of Permr ' EM Building Department nr �< 21'2 Main Street Sewe r6Se�trcAvaiiabrlr Room 100 aferM(ell maitabrlrty s { * nn Northampton, MA 01060 Fora Sets o€StructurafPfansr �if�, -phcrt�(413-587-1240 Fax 413-587-1272 Plo€fSit Ptans z � , E3therSpecrfy ''- APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-'SITE INFORMATION - This Section,to be completedi by office 1.1 Property Address: f� MAP:, Lot Unrt y /"(r�: C7! b�, ZotYeJ- Overlay District EkLSt Drstdct . CS District SECTION-2-PROPERTY OWNERSHIP/AUTHORIZED=AGENT' 2.1 Owner of Record: d 12 L e(P int) Current Mailing Address: �-r36 531 r t A2 Telephone Sign,ur 2.2 Authorized Agent: jesg zrn ® C • Name(Print) Current Mailing Address: C�`1 CPA Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be official Use Only completed by ermit applicant 1. Building n�� (a)Building.Permit Fee 2. Electrical ,v �J (b)Estimated Total'Cost.of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total =0 +2+3+4+5) cal �Q Check Number This Section For OfficfAFUse Only - Date Building Permit Number. Issued: Sianature: v Building Commissioner/Inspector of Buildings Date I 117 ACREBROOK DR BP-2008-0818 GIS#: COMMONWEALTH OF MASSACHUSETTS N1aBlock: 29-214 CITY OF NORTHAMPTON L,C)!: _{){}1 _ PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Perrr;t: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Catettg-Ey_ BUILDING PERMIT Permit# BP-2008-0818 Project# JS-2008-001259 Est. Cost: $2800.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JESSE MONTGOMERY 134274 Lot Size(sq. ft.): 17031.96 Owner: DENNE ELIZABETH Zonin=. URA Applicant: JESSE MONTGOMERY ' 1: iii Hl•t �`u�eylir'. � ,r� ±�ricar�t Ar(dress: Phone: Insurance: P O BOX 329 (413 585-8482 LEEDSMA01053 ISSUED ON:312512008 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 2 REPLACEMENT SKYLIGHTS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Ins�)coor ,I(Phunhing Inspector of NViring 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: Smoke: Final: (9+ "]� 9�4ala��o THIS PERMIT MAY BE REVOKED BY THE TY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGUL ION, f .. Certificate of Occupancy Si nature: aid: Amount: Building 3/25/2008 0:00:00 $25.001662 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo