Loading...
23A-144 City of Northampton r Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building vj�•., =fib,' Northampton, MA 01060 ssp i1� INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 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 I, 1?, —1-�o7t-tas ��, t2� understand the above. (Home owner/reside t signature requesting exemption) 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 x www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Address: /Z ' S� City/State/Zip: Queer 01626 Phone M o6 fi�d Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 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 10.0 Electrical repairs or additions 3 I am a homeowner doing all work officers have exercised their 11.El 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' 13T] Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHo meowners 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. c'J!� - Date: Signature: Phone#: G ` 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#: 4 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable £ Name of License Holder: License Number Address Expiratio Signature Telephone 9.:Re istered Home Im `rovement Contr „,„ Not Applicable £ Company Name Registrati umber 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...... £ 11. `:Home Owne :ExemiD on The current exemption for"homeowners"was extended to include Owner-occupied DwellinEs 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-year 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 buildine 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 La s and State of Massachusetts General Laws Annotated. Homeowner Signature. C SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors` E-1 Accessory Bldg. ❑ Demolition ❑ Net Sin Decks [0 Siding[0] Other[13] VV Brief Description of Proposed Work: 'V�YIAQA�J 4- e Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. lf'New house and oraddition to existing'houstng; complete the following: a. Use of buildirs ne Family Two Family Other b. Number of rooms in ea�kLfamily unit: Number of Bathrooms �--'— c. Is there a garage attached? d. Proposed Square footage of new construc' Dimensions e. Number of stories? f. Method of heating? Fireplaces oodstoves Number of each g. Energy Conservation Compliance. eck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction ' in 100 yr. floodplain Yes No j. Depth of basement or cellar floor ow finished grade k. Will building conform to Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION,, -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i as r of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by t ' it application. Signature of Owner Date Ow r/Authorized Agent hereby declare t t to ments and information on the foregoin Iication are true and accurate,to th st of my knowledge and belief. Signed under the pains and penalties of perjury. F. TIC o GL?u S S',la J C Print Name Signature of Ow r! Date ' Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning 11is colunin to be filled in by Building Pepartment Lot Size ge Setbacks Front Rear Building Height Bldg.Square Footage Open Space Footage % (Lot area minus bldg&payed #of Parking Spaces (volume&Location) A. Has a Special Permit/Variance/F' ing ever been issued for/on the si t�\ IF YES, date issued:! IF YES: Was the permit reco ed at the Registry of Deeds? IF YES: enter Bo Page and/or Document#1 mance/F' id B. Does the site contain/arook, /r ,c+ x"," p `^ ~^ obtained from the —Conservation-- -Commission? Needs to Obtained Date Issued:0 C. Do any signs exist on the property? YES 0 O 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 IF YES, describe size' type and location: _--------_------_ .... ------------ ______/ E Will the construction activity disturb(clearing, grading,excavation, or filling)over 1 acre oriad part ofa 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. �' ©epartmentvse onl�r RI '` r i 5 iI n '7 -- - of Northampton ,tatus,ofPermit �`k$r'{ 4ti t 11 kY k},I�r' x ¢ kr x' t f Ilding Department curd !Cu�TI[PriMeGvay MM I i'212 Main StreetSewerlSeptic Avaifabllrty ! Room 100 �IVaterlhC�eilAva�labhty. Electri�op'Umb n9& Itleo hampton, MA 01060 TWOiS2ts*Of StFUCtuta �Plans't hams t� Gap 413 587-1240 Fax 413-587-1272 PloflSite Plans " 'i',k' ' Mq 0 060 bons Other 5pec�fy`, 1 Tz �, 4 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION : This sectwn 1.1 Property Address to be completed by gff�ce Map Lot Urnt r 1 T::(61f,1Pc4 v/A- t Zone Overlay District �h v10 CB D�stnct Elm St.District r SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �_-(tout s s���� 1 �z I FC 14 el S47 Name(Pri )_ Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS. Item Estimated Cost(Dollars)to be w Official Use Only completed by ermit applicant 1. Building 1;2-a e6 (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=0 +2+3+4+5) ---Z,0-v e;l Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspec tor]'of Buildings Date ID C0 94 File#BP-2015-0078 APPLICANT/CONTACT PERSON SIPPEL R THOMAS ADDRESS/PHONE 121 PINE ST FLORENCE (413)329-0690 Q PROPERTY LOCATION 121 PINE ST MAP 23A PARCEL 144 001 ZONE URB(100) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: REPAIR ROOF FRAMING&SIDING 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 INFO ATION PRESENTED: pproved 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 Signature of Bm ding 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. Contact Office of Planning&Development for more information. 121 PINE ST BP-2015-0078 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A- 144 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2015-0078 Project# JS-2015-000141 Est. Cost: $2000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 20603.88 Owner: SIPPEL R THOMAS Zoning:URB(100)/ Applicant: SIPPEL R THOMAS AT. 121 PINE ST Applicant Address: Phone: Insurance: 121 PINE ST (413) 329-0690 () FLORENCEMA01062 ISSUED ON:712812014 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIR ROOF FRAMING & 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 7/28/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner