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17C-284 (3) O¢S�MpTp DEPARTMENT OF BUILDIN7G INSPECTIONS — /: ` .Z INSPECTOR 212 Main Street • Municipal Building 'moo Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act aS his/her construction sup.;_ .-:,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 backfill), sonotube holes (before pour), a rough building inspection (before work is cancealed), insulation inspection (if required) and a_Bnal_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 understand the above. (Home wner/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 In vestigations Ia 600 Washington Street ~� Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Le4jbly Name(Business/Organization/Individual): Address: City/State/Zip: Phone-4: 7 Are you an emplover?Check the appropriate bog: 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 enVloyees 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 11.0 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' 13.7 Other comp. insurance required.] --'Any app ican a c ec ox must a o out a section oe 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 employees Below is the policy and job site information. Insurance Company Name: Policy r 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. gnature ? I Date: Phone#: 3 (Q ' 4 4 5D vfficiai 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 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...... ❑ 11 =Home.Qwnel `Exemption 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 Gable 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. e omeowner Signature - V �Ol� SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House F-1 Addition ❑ Replacement Windows Alteration(s) El Roofing ❑ Or Doors M Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [C] Siding [0] Other[O]t*ion rief DejpQf Pro ed Work: ff �G Lf�115C7� �`l 7Tk' ALL/BUG ©�1? S7ZUG t Alteration of existing bedroom Yes No Adding newbedroom Yes ✓ No Attached Narrative Renovating unfinished basement Yes V No Plans Attached Roll -Sheet 6a,If i4ew house-ana." addition to existing#>IOUSing,complete the followin4: 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 ion wi i fifes - 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 OWNERAUTHORIZATION-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 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. Pri Name Signature o wner/Agent Date w , t ' 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 — Frontase 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: i (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES IF YES: enter Book Page- and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ® Date Issued: C. Do any signs exist on the property? YES ® NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES NO O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a 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. « w Degoftdnt ase onlyr City of Northampton states of Pence - Y gkk Uilding Department CrirGrlDn�ewa (?er N -r '212 Main Street Sevrrer6SepttcA�a7abrtrty ` _ �; Room 100aterMlellAvatlabt[ity A� 1 COI Northampton, MA 01060 T�vaSetsofSttucfuraTP[ans phone 41P-58 1240 Fax 413-587-1272 Ploffstfe Plans � P 'AT10 T. STRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTIONA -SITE INFORMATION 1.1 Property Address: This section-to be completed by office /.0� 0 LL 7 ST N[ap LQt Untt Overlay Distril ELrtSf-District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT' 2.1 Owner of Record: ors Y ADAms A P_D z3 c-i L -Y s r, fl&kF &r: ,I A oleo Name(Print) Current Mailipq Addre s; Cl�C 4413 -S la'"- 3C� Telephone Signature 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 SC�C�a (a)Building Permit Fee F. 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 Q This Section For Official-Use Only - : Date Building,Permit Number. Issued: Signature: V Building Commissioner/Inspector of Buildings- Date File#BP-2008-0165 APPLICANT/CONTACT PERSON BAIRD BETSY A ADDRESS/PHONE 28 LILLY ST FLORENCE (413) 586-4430 Q PROPERTY LOCATION 28 LILLY ST MAP 17C PARCEL 284 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid T_ypeof Construction: REPAIR TREE DAMAGE TO GARAGE 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 F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO 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 Co sion �2 Signature of Building fficial 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. BP-2008-0165 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-2008-0165 Project# JS-2008-000248 Est. Cost: $50.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sg. ft.): 10890.00 Owner: BAIRD BETSY A Zoning:URB Applicant: BAIRD BETSY A AT. 28 LILLY ST Applicant Address: Phone: Insurance: 28 LILLY ST (413) 586-4430 O FLORENCEMA01062 ISSUED ON.812012007 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIR TREE DAMAGE TO GARAGE 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 8/20/2007 0:00:00 $50.001077 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo