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PI 'ti , . .a....c, ..,;,!.1.44,; _ , ____------ ..„ ,.,_ . , ..,.,,.,,:,._.,.,.::,..,,_,-,•:.„.--„:i,::::_,,.,:,,,:,-,,-,-,-.. ,,,,,,-..:::,:,,,:.: • 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 - • • • L - • • • - • • • •rocess 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- i-n- conjunction.to_the_huilding 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, ! a understand the above. (Ho • ; ow ,1 r /resident's signature requesting exemption) I will call to sc edule all required building inspections necessary for the building permit issued to me. r �. Tofu `A A 1 ail Y 1 Address of work location (� S N RA Ile fkIA 41 ♦ The Commonwealth of Massachusetts wy _ Department of Industrial Accidents 1 --:-. f Office of Investig,ations • k ° ; 600 Washington Street ~ • --mar= hi Boston, MA 02111 :.� . www.massgov /dia • Workers' Compensation Insurance Affidavit: Builders/ Contractors [Electricians /Plumber Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: , City /State/Zip: Phone. #: 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 employees (full and/or part- time). have hired the sub- contractors 6. ❑New construction 2. El I am a sole proprietor or partner- listed on the attached sheet 7. [2 These sub - contractors have ship 0 ,• and have. no envioyees S. beriro, on working for me in any capacity. employees and have workers' 9. Q Building addition �' co �nsuran e.. [No workers' comp. insurance 10.L j Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3. . 1- am-a- homeowner doing-aIl- -work Oars have xezcised their 11 .. _ es . ing repairs or additions myself o workers' co right of exemption per MGL Y comp. 12. a Roof repairs insurance required.) t c. 152, §1(4), and we have n o - employees. [ N o w o r k e r s ' 13. ❑ O t h e r U rVbo di S z 06,..)k - comp. insurance required./ *My applicant that checks box #1 m 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 fire of up to $250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided_above_is_true and_correct _ ___ • Signature: Date: - Phone #: Official use only. Do lint write vi 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. EIectrica1 Inspector 5. Plumbing Inspector _ ___ 6. Other - s. Contact Person: Phone #: i Al., I 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=linprovement Contractor fi .. i , N, ._ . < y -'' 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 ❑ 'I :i U 11 a O ,.? V e k TI O1 t - 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. J 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 1 ort ampton *Nina ces, a e - X ' • • - *, .I. _ " • •- G i tts6enera1. Laws - Annotated. Homeowner Signature I// �' i ,/ i A i , s SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) / New House 0 Addition ❑ Replacement indows Alteration(s) ,8:1 R fang Or Doors + / Accessory Bldg. El Demolition CI New Signs [0] Decks [[f,] Siding [ ] Other [0] Brief Description of Proposed Work: C C)Y` e4-CI- 10 2l6 (knJ0VA NI Alteration of existing bedroom Yes ) No Adding new bedroom Yes J` No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll - Sheet ea, :If NeW ithAeF and of addition to existing houslnci; coml tete 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? \ r d. Proposed Square footage of new construction. Dimensions i i e. Number of stories? r f. Method of heating? Fireplaces or Woodstoves Number of each , I 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 1, , 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 I, MAR-V\ � d . S ULL \U AA as Owner /Authorized Agent hereby declare that 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. M fi�k4 S0LLiv Print Name i, N 8 ,ofc, 1 it ,,,,,..,_ Signa Own= gent Date of 4 Section 4. ZONING Alt 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::__ _._j L: L_____ir . ..__._> R:1._______ Rear Building Height 1 Bldg. Square Footage ,- "° Open Space Footage (Lot area minus bldg & pavedI 1 m ,_? parking) # of Parking Spaces — ` Fill: ' 1 _.�..��.".�� - .n (volume & Location) - — --< --M°" -.__— ___ "•-- -- -•- --. _ -,.. A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW YES , 7 9 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW � YES IF YES: enter Book :; Pagel 1 and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 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 0 NO IF YES, describe size, type and location: - -- D AF tf erfi a an ro osea c es to or a rtions o sighs inEe` edTor`t e ro Pe ? YES NO YP P '; g P P Y ®) 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 9 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 11 *► City of Northampton 5T�r, Building Department �b vaymerr - 212 Main Street a4, v t 3 U u g Room 100 1 14u .0 0 f E es,D�Q Northampton, MA 01060 1-,..06 v,..%,17. - t aw ®- --,,,,,,;.,%.„,:'''.;2 a iik y ` V g n � ,,\ \ , 'p h one 413- 587 -1240 Fax 413- 587 -1272 h ti i �' ��` l p S® x � r t 4 " s E 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 1 _gyp _ , ._ r l�;1 Map Lot Unit Zone Overlay District EIm St' District CB - District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: J� tl L\V�A ,9,68° 36 f Telephone Signature 2.2 Authorize Agen Name (Print) Current Mailing Address: Signature Telephone _ SECTION 3 - ESTIMATED C COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building l o / V c) u (a) Building °Permit Fee 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Fire Protection S� (b) Estimated Total Cost of i Construction from (6) t � Building Permit Fee Check i 0 O �j 6. Total (1 + 2 + 3 + 4 + 5) ^ -= ? heck Number 1 7 1 ,97 � 7 3 is Section For official U se Only Date Building Permit Number: Issued: -- Signature: �- X / /11'C6 Building Commissioner /Inspector of Buildings- Date File # BP- 2010 -0657 APPLICANT /CONTACT PERSON SULLIVAN MARTIN J & KATHLEEN M ADDRESS /PHONE FORT HILL RD HAYDENVILLE PROPERTY LOCATION 12 WINTER ST MAP 24D PARCEL 025 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid 45' Typeof Construction: COMPLETE INTERIOR RENOVATION 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 ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 _ Permit DPW Storm Water Management Demolition Delay s ... /////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. 12 WINTER ST `' BP- 2010 -0657 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 025 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2010 -0657 Project # JS- 2010 - 000700 Est. Cost: $85500.00 Fee: $513.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group:_ Homeowner as Contractor Lot Size(sq. ft.): 5793.48 Owner: SULLIVAN MARTIN J & KATHLEEN M Zoning: URB(100)/ Applicant: SULLIVAN MARTIN J & KATHLEEN M AT: 12 WINTER ST Applicant Address: Phone: Insurance: I ° FORT HILL RD HAYDENVILLEMA01039 ISSUED ON :1/11/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:COMPLETE INTERIOR RENOVATION POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Buitding Inspector Underground: Service: Meter: ,,�;; Footings: Rough:�`�- l `O( :R Rough: House # Foundation: Driveway Final: Final: 54 Final: 57)l /i) Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: 4-9.7-10, Oil: Insulation: a < f it la ''`O 015 f � r � �1i Final. '" � � : Smoke: � Final• THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND RE ;'' Certificate of Occupanc ature: FeeType: Date Paid: Amount: Building 1/11/2010 0:00:00 $513.00 • 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo