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18D-004 (48) , 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 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 Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations [ ., 600 mashin on Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /EIectricians /Plumbers Applicant Information ‘Z-t,0 'Please Print Legibly • Name ( Business /Organization/Individual): R o e,A Ar ') Address: �1 �-.( -y S V\R 1 City /State /Zip: _ b _ MPit 1) 11 Phone #: L1 i3 531- 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. inj New o�lelin construction employees (full and/or part- time).* have hired the sub; 2. ❑ I am a sole proprietor or partner- listed on the attacl'' ship and have no employees These sub - contra f Q ) ( ,- i F working for me in any capacity. employees and ha P ( 'i f c5 s [No workers' comp. insurance comp. insurance t1 required.] 5. 0 We are a corporar ditions 3. ❑ I am a homeowner doing all work officers have exec ditions myself. [No workers' comp. right of exemptia' insurance required.] t c. 152, §1(4), anc employees. [No comp. insurance regaat j 1 , *Any applicant that checks box #1 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 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 fine of up to 5250.00 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 co verage verification. I do hereby certify u der 1 d enalties of perjury that the information provided above is true and correct. Signature: / Date: Li t..) � V 0 ( Phone #: /113 V 3 J - ( leg ) l 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 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 9: Registered Home Improvement Contractor: 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. O Ho O iption 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 - 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) 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 findows Alteration(s) n Roofing n Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [E] Decks [Q Siding [CU Other [p) Brief D Work escription of Proposed 1 C , 1 _. 0 . I ♦1 . C �Q \t S l ©, b lm 1` � 1ll y v' ic CC c 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 existing housing, complete 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 I, r ‘)' l f` rn I , as Owner of the subject property G 1 hereby authorize 1O h Ar c to act on my behalf, in matters relative to work authorized by this building permit application. r Signature of Owner Date I ebb AT-- i LO JO A , as Owner /Authorized Agent hereby declare th he statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. r Signed under i(iy pains and penaltie of p 'ury. Print Name / 4v r i----' ..JU JJE 13 0@i Signature of t` ner /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 F ----------' ------ �-------------- Frontage Setbacks Front r--- r --- -- _ � ~---� �--` [---� F --- r ---- F ---- Side L. R: ��_' �L__ LJ L_ Rear Building Height r F [ __ Bldg. Squar Footage �--- F Y6 �--- F---7 �--- Open Space Footage Y6 (Lot area minus bldg &preu �---7 �--- �---1 F ---- r --- parking) #of Parking Spaces �---� �--- �--- Fill: (volume &c"mmvn) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? �� �� �� NO \_� DONT KNOW �_� YES v_~/ IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? �� NO �� DONT KNOW 0 YES IF YES: enter Book Page and/or Document # �� �� B. Does the site contain a brook, body uf water orvved �� wetlands? NO v�� DONT KNOW v~~� YES �_� IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained *~� Date Issued: �~� ' . �_____--___'_1 �� [. Do any signs exist un the pnope�y7 YES \ NO «�� � -- ---------------- IF YES, describe size, type and tocation: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YES, describe size, type and location: E. Will the construction activty disturb ng, grading on, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YEGK l NO K ) �� �� IF YES, then a Northampton Storrn Water Management Perrnit from the DPW is required. �_ Departrnent City of Northampton status o fPemzrt . Building Department Gtarb CuUDrtve r P .N � _t` `, 212 Main Street sewer /Se f.cAv a�Iabtltty S �� Room 100 UUaterlliUell Avarfa No t# t ampton, MA 0 Q 1060 Two Sets f stru cturaI Plan ' phi x413- 587 -1 40 Fax 4 13- 587 1272 P1atTSi Frans th erSpec�fy APPLJC TO QI aTRu I, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 = SITS INFQ}21gIATION This section to be completed by office 1.1 Pro perty jddress: nn ,, ll �� �1 �� V Iv �� Map Lot Unit J Zone Overlay District Di IQ ����� t6 Eim -St District GB strict SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Reco(`�: 4 I I f� friof G 7Z3 r i' RC) (Print} g�.� m ��� • '. Telephone iV G (� Signature \ L-I I �� 5 6 v`lJ Agent: A1,41 ZRJO /\) \ Name (Print) Current Mailing Ad 2.2 Authoriz e'l dress: ` i-1 0 \ \ � O J\� Signature phone SECTION 3 - ESTIMATED CONSTRUCTION COSTS / )O Item Estimated Cost (Dola to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of _ Conistruction.f (6) 3. Plumbing Bui lding'Permit' t Fee 4. Mechanical (HVAC) 5. Fire Pruleclior� 6. Total = (1 + 2 + 3 + 4 + 5) Check Number it, f This Section For Ocial Use Only Building Permit Number: Issued: Date ffi Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2009 -1080 APPLICANT /CONTACT PERSON ROBERT ARDIZZONI ADDRESS/PHONE 7 LAKESHORE DR HOLLAND (413) 531 -4841 PROPERTY LOCATION 106 DAMON RD MAP 18D PARCEL 004 001 ZONE GB(100) /GI/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out /47 *55 Fee Paid Typeof Construction: INSTALL REPLACEMENT WINDOWS & CABINETS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 051547 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pproved 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 - Permit DPW Storm Water Management Demolition Delay G Z 2 V 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 -1080 GIS #: COMMONWEALTH OF MASSACHUSETTS Lp:Block: 18D 004``` 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- 2009 -1080 Project # JS- 2009 - 001566 Est. Cost: $8000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT ARDIZZONI 051547 Lot Size(sq. ft.): 87120.00 Owner: MOCK WILLIAM D & EVELYN F Zoning: GB(100) /GI/ Applicant: ROBERT ARDIZZONI AT: 106 DAMON RD Applicant Address: Phone: Insurance: 7 LAKESHORE DR (413) 531 -4841 WC HOLLANDMA01521 ISSUED ON:6/24/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS & CABINETS 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 6/24/2009 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo