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17C-142 Lz y of Narfhai tptarn i z $ � jTdassacl�useffs �n _ 5f DEPARTMENT OF BUILDING INSPECTIONS /^ INSPECTOR 212 Main Street • Municipal Building Northampton, MA 01060 ' Y HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sups= ,.`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 buildine 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 occupanev 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. (Hom owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date - O Address of work location / The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 °,M SV•ye www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Auuiicant 1nfortttation Please Prtnt Legibiv Name(Business/Organization/Indi,,idual): Address: City/State/Zip: Phone.#: 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 ° 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolidon working for me in any capacity. employees and have workers' 9 F-1 Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.M I 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' 13.7 Other comp.insurance required.] ---;Axy app a c ec ox st a e ow s oweir workers'compensation policy information. 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 fs?e 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 Investieations of the DIA for insurance coverage verification. I/06,hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. ��Signature• Date: 2-`",-?— C7,2 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 CIerk 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 License Number Address Expiration Date I I I Signature Telephone I 1 9=12eaisteredlone lnipcoveiimentContracfor�w ,„ _im x g � . _, Not Applicable ❑ Company Name Registration Number Address Expiration Date ITelephone SECTION 10-WORKERS'COMPENSATION 1NSURANCE.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"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 Y a SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition Replacement Windows Alteration(s) Roofing Or Doors 171 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[C7] Crief ption pf Pn.roposed l/ioo existing bedroo'n Yes No Adding new-bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 9a-1f ina:complete.the#oCiowitq: 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 consu ucti0 n. 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 ion wi i l`es - No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. 1. Septic Tank City Sewer Private well City water Supply SECTION 7a-r OWNERAUTHORIZATION-TO BE COMPLETED,WHEN OWNERS AGENT OR GONTRACTORAPPLIES'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 I, as Owner/Authorized Agent 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. P nt Napag Signature of wner/Agent Date w . ^ ` 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 Setbacks Front Rear Building Height Bldg. Square Footage % Open Space Footage 7- % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Special Perm it/Variance/Finding ever been issued for/on the site? — '---_ IF YES, date issued: � ' IF YES: Was the permit recorded at the Registry ofDeeds? NO �� DON'T KNOW YES \�� m m IF YES: enter Book Page, / and/or Document#� ! _________ �� �� D. Does the site contain u brook, body of water orwetlands? NO �~��� DON7 VV �~�K0� YES \�� IF YES, has e permit been or need tu ba obtained from the Conservation Commission? Needs�obe obtained v�� Obtained �~\ Date Issued ` '''^~~~ `~~^ ~~^~'^'~~ v~~� ~~~~^~~ \�� ' ~~^~ '^~~~~� C. Do any signs exist on the proporty �� ��� YES �~/ NO \~~/ IF YES, describe size, type and location: D. Are there any proposed changes too additions ofsigns intended for the property? YES NO IF YES, describe size, type and location: } E. Will the construction activity disturb grading,excavation,mfilling)over acre or ishpart ofacommon plan that will disturb over 1acre? YES � ) NO � ) �� �� IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only- P City of Northampton Status-ofperqlt 80ding Department Curb OV vu Perm 212 Main Street S awe dsep i dflab Gty s } £ µ Room 100 1N erl1[e[iAvatlab�it#y Nor#ttnpton, MA 01060lavoSefs of 5ttvctu{ 7 Pfa�s ` LM I phone 413-587 4240 Fax 413-587-1272 Piof/site Plans ©thef Specify _,' APPLICATION TO cgg1 �cT-,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECT[ON 1-SITE INFORMATION--- ----- 1.1 Property Address: This section to be completed by office /� � Lot Unit Zone Oveflay District .Elm St.District CS Districf SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �!►a /:,,D �'�a G a L/-Q.v'd'lc . L I'- /yt i"Y�� U Name(Prin4 Current Mailing(Address: Telephone 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 J (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 This Section For Of icl;M Use Onl Tls'stued.Building Permit Number. Signature: Building Commissioner/Inspector of Buildings Date <; BP-2008-0120 Qs#:r COMMONWEALTH OF MASSACHUSETTS iO: 17C-142 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Catef4ory BUILDING PERMIT Permit# BP-2008-0120 Project# JS-2008-000188 Est. Cost: $1500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 15812.28 Owner: MOCZULEWSKI PHILIP J&THERESA A Zoning: URB Applicant: MOCZULEWSKI PHILIP J & THERESA A AT. 126 HIGH ST Applicant Address: Phone: Insurance: FLORENCEMA01062 ISSUED ON.81312007 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL WINDOWS & SIDING ON PORCH 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 8/3/2007 0:00:00 $25.002267 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo