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36-127 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 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 your), 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 ho m owner hires other trades to perform work(electrical, plumbing&gas) the homeow e will be r ponsible to make sure that the trades hired secure their proper permits in o unction the building permit issued, and that they get their required inspect' ns. a. ure of individual trades to secure the permits and inspections as required Y the 'ect until such time as the proper permits and inspections are made I, understand the above. (Home owne rest nt's s nature requesting exemption) I will call to sched a all require uilding inspections necessary for the building permit issued to me. Date Address of work location -`° The Commonwealth of Massachusetts -" Departtent of Industrial Accidents Office bf Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print Leaibiv Name (Business/Organization/Individual): CA*A6V CE IV',G- Address: p.0 �,Vx !I VvS City/State/Zip: " VA*, ®to%p Phone#: 01'5-330~f3k-17 Are you an employer?Check the appropriate box: Type of project(required): 1.Q�I am a employer with t_ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 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.[Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *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. 'Contractors that check this box must attached an additional sheet showing the narne 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: TV c 0"S tj _ Policy#or Self-ins.Lic. #: `J( ?CJ Qi��'�L 7 Expiration Date: 4-074- Job Site Address: 9`1\ •3, C?�C- C,m&cp W 11 City/State/Zip: dlocj 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. I52 can Iead 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. I do hereby certi c r the pains and penalties of perjury that the information provi bo�v{e is true and correct. Signature: �=a Date: a o° Phone#: e.105 3aaQ-077 Official use only. Do not write in this area, to be completed by city or town offlciaL Citv 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#: f SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: ` Not Applicable ❑ Name of License Holder:_ >jt�rsVU A-�,�,w rr 7(©`TT,Q License Number 6-a -off Ad s Expiration Date Signature Telephone 9.Registered Home,Improvement Contractor:, Not Applicable ❑ it 314.15 Company Name Registration Number WX ` ,kc'A-3, LQ. � kytA�� r4_ YyK C11 ty 1'aL-(0--C)a Address Expiration Date Telephone N�3 3'atyl?T SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MG.L.c.1522§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 Owner ExemOti h`- 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 wor or you under this permit. The undersigned"horn certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, a Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature t M ' SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 15 Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E:] Siding [0] Other[O] Brief Descriptio of Proposed Work: fl!E 14. C �.t,K Alteration of existing bedroom Yes No Adding new bedroom Yes ✓ No Attached Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roil -Sheet 6a. If New house and or addition to existing housing, complete the following: 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 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 I, 1rA©l\S i�l'P t Dt-Q _ as Owner of the subject property hereby authorize "T'� F r. to act on my behalf, in all matters rel ive to w rk authorized by this building permit appli ation. Signature of Owner Date as Owner/Authorized Agent hereby declart that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed u er the pains and penalties of perjury. Print Name 'y 1 Signature of Owner/Agent Date P 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 _._, __...__.' ._. . _,�.. . . ..._._..._..,., Setbacks Front Side L: ..,,._._._, R:,,,,-..__.., L- .. R __ -.-._.,. Rear __.„_..' _.... _._.... Building Height Bldg.Square Footage % _..,_._.._. _..,..__ Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book ` Page and/or Document# 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 Obtained , Date Issued: C. Do any signs exist on the property? YES NO rX IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading,excpvation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. a Department.use only City of o h i t tus of Permit r^ Building partment Cut(Dpyeway Permit 212 M Ih`,�Streg P - 3 2008 erlse ptrcAyaaabildy ROM i00 Wa /Well:Availability - Northam ton, 01QfQ -- T4vo et otStructural Plans phone 413-587-1 40 F�bd 4 �Z ,"1 ' c����'S Plot1 ite Plans -'j. L N. ther Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address. ;L"A1 civ. Map Lot Unit r%°ceo're, vv"" E'i()CGP Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: II �� 1Yl�a :tee ��tr t3� :� .� 'VtQz oLOCR-7 Name(Print) Current Mailing Address: <NzAa Teleph n Signature 2.2 Authorized Agent: Y, �°t *7%-- Name Current Mailing Address: W��-rr� q%-6— �% 40— �7 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building SS (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 L J { This Section For Official Use Only Date' Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2009-0224 APPLICANT/CONTACT PERSON FLANNEL CONSTRUCTION INC ADDRESS/PHONE P.O.Box 933 WILLIAMSBURG (413)320-8177 PROPERTY LOCATION 271 BROOKSIDE CIR MAP 36 PARCEL 127 001 ZONE URA/WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out Fee Paid Typeof Construction: REPAIR ROOF&FRONT STEPS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 76752 3 sets of Plans/Plot Plan THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION 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 Demolition Delay O� Signature of Building Officiftf ate 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. N �r BP-2009-0224 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Perrnit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2009-0224 Project# JS-2009-000291 Est. Cost: $902.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: FLANNEL CONSTRUCTION INC 76752 Lot Size(sq.ft.): 26528.04 Owner: MIGLIORE HOLLY A Zoning:URA/WSP Applicant: FLANNEL CONSTRUCTION INC AT: 271 BROOKSIDE CIR Applicant Address: Phone: Insurance: P O Box 933 (413) 320-8177 Workers Compensation WILLIAMSBURGMA01096 ISSUED ON:91912008 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIR ROOF & FRONT STEPS 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 9/9/2008 0:00:00 $55.001052 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo