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17A-267 Lxfu IIfa�I� trn Y DEPARTMENT OF BUIL.DD%,TG INSPECTIONS INSPECTOR 212 Main Street • Municipal Build my 'a ,y Northwnpton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act a� l.is/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 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 backTiill). sonotube holes (before pour), a rough building inspection(before work is concealed). i-nsulation inspection (if required)and a_fnal_buildina 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 r V//� understand the above. (HY11 e owner/resident's signature requesting exemption) I will to schedule all required building inspections necessary for the building permit issued to me. Date �� 7 Address of work location ' The Commonwealth of Massachusetts -� Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston, IIIA 02111 www.mass.goti/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone.#: Fyou an employer?Check the appropriate box: Type of project(required): I am a employer with 4. Q 1 am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 3. Q Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp•insurance.: required.] 5. 17 We are a corporation and its 10.❑Electrical repairs or additions 3.V I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption'per MGL 12.71 Roof repairs insurance required]t c. 152, §1(4), and we have no employees. [No workers' 13.71 Other comp.insurance required.] AxY aPP-1i"ca­n- c ec Zs box 41 must also rill out the secaon befow showing their 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 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 of up to 3250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of InvestiL'ations of the DLA for insurance coverage verification. I d ereby certify under the pains-and penalties of perjury that the information provided above is true and correct Phone : L6. Other only. Do not write in this area,to be completed by city or town officiaL n: Permit/License Ir hority(circle one): Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone 4: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9- � � � Not A pp licable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10 WORKERS'COMPENSATION-INSURANCE.AFFIDAVIT(r4-G.L.,c.f52,,§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 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 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 ❑ 1, Accessory Bldg. ❑ Demolition ❑ New Signs [Q] Decks [[� Siding[Qj Other($i Brief Description of Proposed CA SL&I( new i"V do Work: 'l e_ - Aiteration of zxrsting bedroom Yes No -Adding newtedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa Ef�hfev�koas�and.o€� ddi€io�rr_€���xis€Fn�:�ioui�tct.�a�ptete.€���a[fov�iig• 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 uc ion wi i 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-OWNER.AUTHORIZATiON-TO`BE COMPLETED,WHENt OWNERS AGENT-OR CONTRACTOR:APPLIEE'FOR;Bt11LDINa.PERMIT �. as Owner of the subject property hereby authorize to act on my behalf, in ail matters relative to work authorized by this building permit application. Signature of Owner Date 7Agentas Owner/Authorized ereby declarelth t 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. Print Name dddd 4 �•. � p __41 i t Signature of OwnerlAgent Dates e 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:r R- Rear Building Height Bid-.Square Footage % Open Space Footage % (Lot area minus Sldg&paved arkine) #of Parking Spaces Fill: (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 0 DON'f KNOW YES 0 IF YES: enter Book Page! and/or Document B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES O 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 Q NO NOV 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 1 acre? YES NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. (09 Ci/o—p---n velCll 1,�n/2,( DNS zG rat o City of Northampton StatitofFen , Building Department CurbrElrt*�eueszntt 212 Main Street SeweffSeptrRuaifairf � x Room 100 rte°€erteAvaabrrr n ` . Northampton, MA 01060 pro Seoi St>ucferral Plans - _ " pk>gr'le 413-587-1240 Fax 413-587-1272 BtoSPians r Oth�rs�e+rt� -- z APPLICATION.TO CQNSIRUCT,aALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING �S-ECTIOU-1=SITE INFCIR M ATION' - This sectfdiTta be cotnplefe<fb. ffice 1.1 Prooerty Address: b OAK ST. �(f I&e.. NIapE dot _ Etat Zorse Overfay©rs#ctct 0 0D 2 �ESt District CS Drstrrct SECTION 2-PROPERTY OWNERSHIPIAUTHORIZEDrAGEN:T 2.1 Owner of Record: A e (Ip D,fK 57, Name(Print) Current Mailing Address: e5- 07q Telephone 0 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 I( --Building:Permit Fee 2. Electrical 4;E15YEstimated Total Gost.of Construction-from 6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC tJ 300 5_ Fire Protection Chi N�� 6. Total=(1 +2+3+4+5) j '300 Check Number _ This Section For Offitf5ruse-0nl - -- DaCe Building Permit Number. Issued: Signature: Building Ccmmissionerfinspector of Buildings Date 96 OAK ST BP-2008-0357 GIS#: COMMONWEALTH OF MASSACHUSETTS Map_Block: 17A-267 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-2008-0357 Proiect# JS-2008-000515 Est. Cost: $1300.00 Fee:$25.0 0 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sg. ft.): 15594.48 Owner: HALE TED OLIVER&MOLLY zoning: uRB Applicant:- HALE TED OLIVER & MOLLY A 7. 96 n^.K C-I- Applicant Address: r Phone: Insurance: 96 OAK ST (413) 585-0791 O FLORENCEMA01062 ISSUED ON:101312007 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL WOODSTOVE & CHIMNEY 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: THIS PERMIT MAY BE REVOKED Y THE CITY OF NORTHAMPT ,UPON VIOLA O ANY OF ITS RULES GU IONS. Certificate of O a cy Signature: FeeType• Date Paid: Amount: - Building 10/3/2007 0:00:00 $25.00463 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo