The URL can be used to link to this page

35-204 Lzty of Nort4allipton z � � �assaclluseffs - 5" DEPARTMENT OF BUILDING 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 i.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 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 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 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 Lv �i C lewre I, 410 5 understand the above. (Home owner/resident's signat a requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location 2- 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/PIumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone.#: 7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. F� I am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no P-rnployees These sub-contractors have g. E]Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition ti-4o workers' comp.insurance comp. in„":rance•t required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 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 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees.[No workers' 110 Other comp.insurance required.] 'tiny apphan that c ec ox 91 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. :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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. o hereby certify under pa' s andpenalties ofperjury that the information provided above is true and correct Si ature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: SECTION 8-CONSTRUCTION,SERVICES' 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9'Rearstefed`Home Impiro"veiiienf.Contractor� Not Applicable ❑ Company Name Registration Number Address Expiration Date 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...... ❑ 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"certifie and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State anl 0ocal Zoning Laws and St a of Massachusetts General Laws Annotated. Homeowner Signature 0 1 SECTION 5-DESCRIPTION OF PROPOSED WORK check all applicable New House ❑ Addition [J Replacement YAdows Alteration(s) ❑ Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs (01 Decks [[] Siding Other[p] Brief Des iptio of Propos Work: N� � �f �'t� ',�(' i'EG/"f (�c•'�YY3'u�"! �` �j�s�/ '/ Alteratiori of ez'isting bedroom -Yes V No Adding new-bedroom Yes � No Attached Narrative Renovating unfinished basement Yes _ , No Plans Attached Roll -Sheet sa_If N`ew:house and or-:acld�tlan;fa erstincli°ti©tisrna coriglete#ate follo�vr'iic: 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 ruc ior�withir� t00yr. floodptam— ----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-7 SECTION 7a-OWNER AUTHORIZATION-TO BE-COMPLETED,WHEN' OWNERS AGENT OR 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 -------------------------- --- L°r"E �c,-.-pis � as Owner/Authorized Agent hereby declare that the staternents 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 Signae of Owner/Age Date JOK ~ . ^ ~ 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 Lot Size Frontage Sctbacks Front Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved jo #1 of Parking Q-1— (volume&Location) A. Has a Sp/cial Perm it/Variance/Fi nding ever been issued for/on the site? - DON7 KNOW 0 YES ------ IF YES, date issue&' IF YES: Was the permit recorded at the Registry ofDeeds? �� KNOW�� DON7 KNO YES IF YES:� enter Book Page and/or Document#' | �� B. Does the site contain u brook, body of water orwetlands? NO V�� DO07KNOVV �~� YES �~� IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs tobaobtained �~� Ob�a[�ed �~� Date �~� x~~� ' . C. Do any signs exist on the property? YES K ) NO �mY IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES x~� NO e( IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading vodnn.or filling)over 1 acre nrisdpart ofo common plan that will disturb over 1acre? YES ��) NO 0�) |F YES,then a Northampton Storm Water Management Permit from the DPW iurequired. Qep-artment use only w x'.» 1' i : City of Northampton Status oferrrut � Building Department Cuytld e` �ercn � I .� � �� 212 Main Street Svr�eseAaitab �� Y Mki Room 100 1G1laferetlAvaila6iCity a Northampton, MA 01060 i�vSets oSfrricrral Prar�s S EP 2 7 pl46a 413.•-�87-1240 Fax 413-587-1272 P otValte Ptans C?tPALI'CAT10N''TC1 CTRUC ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION I -SITE INFORMATION' ' ice " 1.1 Property Address: This section to be completed by off (7 W1 Ifl[ap tqt !"Unit Zone Overlay Disfrict: . ce /� Elrti St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: e5 se-, -r; �r9r�► � '� /oZ�� 'u�/3 /�i r� +� �/o��CP Name Print) Current Mailing AdPss: ` Telephone j' gnature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building dw C�c� (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 6. Total=(1 +2+3+4+5) Check Number / a This Section For Official Use Only Date' Building Permit Number_ Signature: Building Commissioner/Inspector of Buildings Date BP-2008-0341 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-2008-0341 Project# JS-2008-000491 Est. Cost: $3000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group-L Homeowner as Contractor Lot Size(sq.ft.): 57499.20 Owner: CAMPOSEO JAMES M&LORI J Zoning: SR Applicant: CAMPOSEO JAMES M & LORI J AT. 1268 BURTS PIT RD Applicant Address: Phone: Insurance: 1268 BURTS PIT RD (413)586-1581 (� FLORENCEMA01062 ISSUED ON.912712007 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT DOORS,WINDOWS & REPAIR SIDING 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 9/27/2007 0:00:00 $25.001529 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo