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23D-172 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 • 11 - • • • - • • • .xacess 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 ----- _- - - - - pe -ts-in -conj unction_. to_ thebuilding ._permitissued,_ 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 1, 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. --ate Address of work location = The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations te= 600 Washington Street Boston, MA 02111 ;� www.mass.gov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): SC-e) 1 i Address: 6 U L L.PC City /State /Zip: / L.-/D i) 01 V Phone. #: 5-3? V Are you an employer? Check the appropriate box: Type of project (required): 1. Q I am a employer to er with 4. Q I am a general contractor and I 6_ 0 New construction employees (full and/or part - time).* have hired the sub- contractors listed on the attached sheet. 7. Q 2_ am a sole proprietor or partner- Remodeling ship an�l have n a loyees These sub - contractors have. 8_ Q Deno; on for me in any ac' employees and have workers' worltin g y cap ity 9. Q Budding addition [No workers' co. insurance comp._nlsrrancP_ p required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. Q I -am -a homeewaer -do g-a work -- office _hav ercised their ___11 J glumbmg -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' 13.0 Other comp. insurance required_. *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. Iam 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 , re of up to $250,00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Offi-A of Investigations of the DIA for insurance coveraze verification. _ I do_hereby certify under the pains and s enah%ps of perjury that the information provided _ahave_is_true_aud_correct __ _._ - Si 1[�7 �. Silas tore: , �/ � /A � � ate. Phone #: > J J Official use only. Do not write In this area, to be completed iy city or town off ciaL City or Town: Permit/License #__ Issuing Authority (circle one): -`I: Board of Health 2. Buil -ding Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector 6.Other ! Contact Person: Phone #: f SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: --�, Not Applicable 0 Name of License Holder : R 1 L ( " t f& D ,3 � �- v I ? 0( / License Number Address Expiration Date �C–) Signature 1744 1744 \ Telephone t l 3 7 9.. Registered Home improvetttent Contractor j w Not Applicable ❑ R \ c M Y k.(1v � i b Company Name Registration Number Z� v LC- A- A V im, `?j - - D Address Expiration Date `1 \<- Telephone S 3 J -(a la I- SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G 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 ❑ .1I t44"000 _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, ui is intended to lie, 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 o ampton e r i tna ces, . a e :r . i • ` . _ r. * - ® tts-Genera1 aw-s- 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 El New Signs [0] Decks [E ] Siding [0] Other [ltij' Brief Description of Proposed 1' Work: / ii)0 /) S O Ve, Alteration of existing bedroom Yes _ No Adding new bedroom Yes No Attached Narrative . Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa_ i'f.Ne*tiouse and ar eck�'it o�.to "existinq'ho is�ncl,`complete the .foliowlrtq: 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 act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 1 Aff4/.441g' ar" A,k , as Owner /Authorized Agent declare that the - tements a.: information on the foregoing application are true and accurate, to the best of my knowledge and belief. Si. ned u -er the pains and pen - • • -jury. Pn N. a IMF, 4r111W Signatur of Offer /Agent Date J A 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 :M.___._.._. L:_______: R:'....____. Rear £ _.� _ . Building Height :— - °- -.., Bldg. Square Footage -- Open Space Footage % (Lot area minus bldg & paved parking) I # of Parking Spaces Fill: (volume & Location) i i __. w._ ................— A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES IF YES, date issued:; i IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book i Pagel and /or Document # B. 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 0 , Date Issued C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: DD.` re— tFier`e any proposed changes to or additions o signs nten edfor e property ? YES 0 NO 0 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. City of Northampton Building Department C�ar�Onevuayer� 212 Main Street se - ® mu . "ma Room 100 Nocthampton, MA 01060 phone 41311587 -1340 Fax 413- 587 -127 a E APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Prope Address: This section to be completed by office ,2 L P:9 Map Lot Unit eta 64' 01010-z_ Zone Overlay District EIm St. CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: c - _ A -;fy, 2:400:4 //( 3 10 / Name lj urre t ailing A r ' gr �..�a«��/ TelEp'ho e gnature . 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 permit 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) d i) 5. Fire Protection J ) 6. Total = (1 + 2 + 3 + 4 + 5) I Check Number !a' 7 / Ll 45" This Section For Official se Only Date Building Permit Number. Issued: Signature: Building Commissioner /Inspector of Buildings Date 48 BAKER HELL, RD BP- 2010 -0504 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23D - 172 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- 2010 -0504 Project # JS- 2010 - 000697 Est. Cost: $2750.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RICHARD SCOTT 83108 Lot Size(sq. ft.): 23478.84 Owner: RYAN G ANTHONY & AUDREY J 7nnin : tIRB(1NNZ Applicant: RICHARD SCOTT AT: i3 BAKER H'LL RD Applicant Address: Phone: Insurance: 20 BULLARD AVE (413) 533 -6340 HOLYOKEMAO1040 ISSUED ON :11/6/2009 0 :00 :00 T() PERFORM THE FOLLOWING WORK INSTALL WOODSTOVE 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: O /C THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIO Certificate of Occupanc Signature: FeeType: Date Paid: Amount: a Building 11/6/2009 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo 0 i , ) o \s' se\ ' 80' . „, 23D-145 # Craig A. Porter F/ Jason M. Todd Book 3217 Page 62 i Book 5462 Page 229 I CO - 13 00 c)es 0 1 0 SeS j iwiT(,,,, fe . � ! ,, ° ff - -J I aS I D.' 0 i < D-d -> . 11 , • 1 ----- 0 i i L A 0 �' i,,,,,,, - 1 Jce ' i ‘ r.6 / i • sj AV It WTIVSLOW . ,