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23A-161 (3) r k 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 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. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Tate Address of work location r J The Commonwealth of Massachusetts Department of Industrial.4ccidents Office of Investigations 600 IEashington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/In divi dual).' �� r -6 i Address: City/State/Zip: / Phone#: Are you an employer?C—iFeck the appropriate boa: Type of project(req' fired): 1.❑ I am a employer with 4. ❑ I am a general contractor and I have hired the sub-contractors 6. ❑New construction em es(full and/or part-time).* ` 2 am a sole proprietor or partner- listed on the attached sheet. 7. U Remodeling These sub-contractors have ship and have no employees 8. ❑Demolition working for me in any capacity. Unlployet_s a,td have H1u1kc1's' [No workers' comp. insurance comp. insurance.* 9. Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing all work 1 - Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.F-1 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' la•❑ Other comp.insurance required.] *Any applicant that checks box 111 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 thepolicy and jab 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 we11 as civil penalties in the form of a STOP WORK ORDER and a fine of i ip to,$250 00 a clay against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi nder the pains and ties of perjury at the information provided above is true and correct.. Sianature: A Date: Phone#: ' nfficirrl rrse nrtll. Do not write in this area,to be completed by ciol or town uncial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Flealth 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 Su ervisor: Not Applicable ❑ Name of License Holder License Number � � L AddresA Expira ion Date Sig e Telephone 7 C ister Home Im rovement:Cotitractor. Not Applicable ❑ Coma N Regissttraftio"n� Numbed, Address Expiration Date 1 Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G'.L.c.152,§25C(8)) 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 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 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)ofthe Massachusetts General Laws Annotated,you maybe l a�lrlia lr rut I,eisuu(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Buildin Code.City of - - Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0) Other[p] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a if New house'and or addition to`ekisting housing','Comptete 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 as Owner of the subject property hereby authorize to ac iy behalf, in all _ relative to work aut or ed by this building permit application. Sign ture of Owner Date as Owner/Authorized Agent her die are that the statements an information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains andpr ies of perjury. e J � Print Name i na Owner/Agent Date 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 m__m..' R _.._ Rear Building Height Bldg. Square Footage __._ Open Space Footage ° /o (Lot area minus bldg&paved parking) #of Parking Spaces - •. „-~ Fill: f volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES IF YES, date issued:' IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page and/or Document#' S. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 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 ! - IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES NO 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 7 acre? YES NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. D C Mart " Lse !11� y City Of Northampton �� ry Building Department Curb C�ttlDr�veway Permi# 212 Main Street Sewer/Septic varlab�Ti#y d Room 100 1Na#er/tNefl�#vallabllity Northampton, MA 01060 Two Sets of StructuraiPlans '- phone 413-587-1240 Fax 413-587-1272 PIot,Sfte Plans s e Qther. .Perafy. 5 ,x PLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot Unit y Zone I Overlay District Et m St GB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner ecord: ' / � ✓ Na/me(Pri t) Current Mailing Address: Telephone Signature^� 2.2 Authorized Agent: Name(Pr Current Mailing Address: Sig r Telephone SE ON 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only coApleted by ermit applicant 1. Building \ (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) Cheek Number a' This Section For Official Use Onl Date Ruiiriing Permit Number: issued. Signature: Building Commissionedinspector of Buildings Date 68 PINE ST BP-2015-0608 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A- 161 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2015-0608 Project# JS-2015-001176 Est. Cost: $2400.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JAMES ROBERTS 99404 Lot Size(sq. ft.): 14026.32 Owner: WAKIN ELEANOR Zoning:URB000)/ Applicant: JAMES ROBERTS AT. 68 PINE ST Applicant Address: Phone: Insurance: 30 Edwards Rd (413) 527-6078 WESTHAMPTONMA01027 ISSUED ON:121212014 0:00:00 TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE FRONT ROOF 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 12/2/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner