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17A-056 HOLE OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CVR 1083.4 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 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, 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. Date 1 C Address of work f ; location m -- 1�i-_e C0111711o71Yt'CQf, O1,Vassacl'ZL.se:a -x- _ DeT r rme:ll of 1ndzzsr,-ia?_-14ccid'ents ©;T- 2 Ce OJ I71Y°Sriy afrons - _ 600 IT shin ton S -eer Bas-on, AL-1 0211I - ri'n'x'.mass.a ot'dia Workers Compensation Insurance Affidavit: Builders,%Contra ctorsiEIecrricians,Tl?imbers —mAicant Infor'nation Please Print Legibly S�ve- (��klHek ✓ 2ii1 (BusinessiOr�anzarior'indi idua.'1: �cjQr�SS: City;!State/Zip: ' " 14Phone - D � Are you an employer'Check the appropriat box: Type of project(required): . I am a general contractor and I 1.❑ I am a employe 4 r with ❑ 6. C]New construction employees (full and/or part-time).* have hired the sub-contractors _.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no emplovees These sub-contractors have S. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance. required-1 5. We are a corporation and its 10.❑Electrical repairs or additions I am a homeowner doing all work officers have exercised their 11.7 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] ' c. 152, §1(4),and we have no employees. [tio workers' 13.7 Other comp.insurance required.] *any applicant that checks box=l must aiso Sll out the section below showing their workers'compensation policy in:errration. Homeowner;who submit this affidavit indicating they are doing all work and then hire outside contractors must subnvt a new afn"cavit 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 errmloyees. If the sub-contractors have errmloyees,they must provide their workers'com—policy number. I am an employer that is providing-workers'compensation insurance for my employees Below is the policy and job site irfor,;,at; lns:=ce CoiTivan"v 1v7 ame: Policv:�or Seif--ins. Lie. 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 S 1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine o:`up to S-7 50.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigarions of the DL-k for insurance coverage verification. I do hereby tify un ze pains penalties of perjury chat the information provided above is true and correct. Ci_nature7 Date: Phone�-: I t ?ffcial use only. Do not write in this area, to be completed by city or town of ciaL Cite or Town. PermitfLicense=` I Issuing Authority%(circle one): 1.Board of i ealth '.Building Deaartment 3. City/Town CIerk -'.Electrical Inspector 5.Plumbing Inspector 6. Other ji Con.2cr Person:: Ph ore SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Suoeriisor7 NotAppiicable ❑ Name of License Holder: License Number 3 zc;32 adaress Expiration D,atee, Signature Telephone i.Feaistered Home lmoroverne Cantractor ` _ ,, Not Applicable ❑ Dion ,omoanv Name Registration Number ddress �1 Expiration Date LL►IrcPcr Telephone C"�/3 ' Cu.1'Z-12 E ECTION 1:0-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G L.c.152,,§:25C(6).) Forkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result the denial of the issuance of the building permit. oned Affidavit Attached Yes....... ❑ No...... ❑ il_. Ho��:Oie - e %Qn The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families allow v i .ividual c r�it ,ho does license provided that the owner acts and to a�tuw SiiCu 1'iurricilWrter to cn:n�c an'uiui viuuai-Lvi iu.e who u02S not pCSSeSS.. that 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 ofEmployers 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 Buildina Code,City of Northampton Ordinances, State and Local Zoning s and State of Massachusetts General Laws Annotated. Homeowner Signature I .. i SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aflolicabie� i New House Addition C Replacement Windows Alteration(s) ❑ Proofing Or Doors J;? I I I i Accessory Bldg. ❑ Demoiition ❑ i New Signs [pj Decks [77 Siding; Other[pl 1 Brier Description of Proposed RE PCAC S-i Q f Nq � D aoV , P-(tAe+ 900FINQ �'Jork: P �\// Alteration of existing bedroom Yes No Adding new bedroom Yes No A-.ached Narrative P.enovatin_e unfinished basement Yes No Plans At ached Roll -Sheet sat If Nevin house arid`ar addition.to exr`s.ting housma.como ete the foifowina 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 Woedstoves Number of each c. Energy Conservation Compliance. Massoheck Energy Compliance form attached? h. Type of construction i. Is cons ruction 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. U'Jill building conform to the Building and Zoning reguiaticrs? Yes No. Se_,tir Tank Ci, Sewer Private well C+ry'r.'ater Supply y ISECTION 7a--OWNER AUTHORIZATION TO EE COMPLETED-WHEN OWNERS AGENT OED CONTRACTOR APPLIES FOR BUILD1NG=PI=RINIT I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized'^ uilding permit application. I Signature of Owner Date as Owner/Authorized Agent hereby deciare that the statemen 3 and infer;ation on the foregoing application are true and a=-,rate, to the best of my knewiedge and beiief. Siene noon th and pr e�n aitm o penury. _L Pint\ame . � i j l cnature of Cwner;,gent =:e ' ^ ' � I Section 4. Z ON ING All Information Must Be Completed. Permit Car Be Denied Due To Incomplete Information Exis—inz Proposed Required'a Zoning Tnhis coiumn be filled in by Building Department Setbacks Front Rgae Building Height Bldg. Square Foo=e % I to ontage Open Space Footage % F-7— 1 (Lot area minus bidg&paved aces of ParkinL7 Sp (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONTKNOY 0 YE 0 IF YES, date issued / IF YES: Was the permit recorded at the Registry ofDeeds? NO DON7- KNOW IF YES: enter Book Page and/or Document#i B. Does the site contain a brook, body of water orwetlands? NO 0 DONTKNOYY 0 YES 0 IF YES, has permit been or need to be obtained from the Conservation Commission? _-_-_-_--, Needs tobenbtaned �-\ Obtained v—\ �atebsued� � � ^ �~* ' \_� ' C. Do any signs exist on the property?y� Y[S �_/ NO IF YES, descr�be size, type and location- D. Are there any proposed changes to or additions of signs intended for the property 7 YES 0 NO 0 /FYES, describe size' type and location: E. Will the construction activity disturb(clearing,gradingexcavation, urfi//ing)over 1 acre orisit part ofaconninc, pian that wi||disturb over 1acre? YES NO 0 IF YES,then'allorf6��ohSDor—m-Mt—er'M��nfPennit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department curb Cut/Driveway'Permit 212 Main Streel Sewer/Septic Availability Room 100 watedW411 Availability Northampton, MA. 01060 Two Sets of Structural Plans phone 413-587-1240 f=ax 413-587-1272 Plot/Site Plans IOther Specify APPLICATION 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 f L i ke Zone Overlay District / —O /-e- 41a a Elrn St District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Na Print) Current Mailin ddress:�t � C C,Y Telephone Signature 2.2 Authorized Agent: �r Name(Print) Current Mailing Address: Sign4za Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit acolicant 1. Building (a)Building'Permit'Fee i CJJCCII 2. Electrical (b)Estimated Total Cost of 1 Construction from(6') 3. Plumbing Buildingg Permit Fee r 4. Mechanical(HVAC) o` (�� '�oo r J Uo 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number 1 50z_ I This Section For Official Use Only -Date_ Building Permit Number: Issued: Signature: Building.Commissipner/Inspector oiBuuamgs Date File#BP-2009-0005 APPLICANT/CONTACT PERSON PARMENTIER CHRISTINE S ADDRESS/PHONE 3 JOAN ST SOUTH HADLEY PROPERTY LOCATION 123 LAKE ST MAP 17A PARCEL 056 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid uildiu Permit Filled out wee Paid 1 Typeof Construction: Roofing siding,doors 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 LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9j04ATION 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 Z"X-, 0 '7 to, 1 0 Signature of Building 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. °- BP-2009-0005 r 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) Cate og U-. BUILDING PERMIT Permit# BP-2009-0005 Project# JS-2009-000006 Est. Cost: $17500.00 Fee: $75.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin RENE G DION 109853 Lot Size(sq.ft.): 22564.08 Owner: PARMENTIER CHRISTINE S Zoning:URB Applicant: PARMENTIER CHRISTINE S AT. 123 LAKE ST Applicant Address: Phone: Insurance: 3 JOAN ST SOUTH HADLEYMA01075 ISSUED ON.71112008 0:00:00 TO PERFORM THE FOLLOWING WORK-,Roofing, siding, doors 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 7/1/2008 0:00:00 $75.001302 212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo