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24D-249 (3) , , , ,. __ int 4 as 0 .............3 , Wl I 4 w exiactsg. i d .9 2 \ " r cl??1/ 1 q t9 , '4- MOORA /t 1 C-1 \N'Q\ 6 , 1 _,# -- Li c (-) kt Ara. ArfatA l i i i' A Imo \,.o N M r '. 1 Nr, 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 jermits 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 DI LAY the project until such time as the proper permits and inspections are made 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 Date Address of work location . , , . , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations . 600 Washing,ton Street „s Boston, MA 02111 www.mass.gov/dia . ... -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeiblv Name (Business/Organization/IndividuaI): Pe't Address: 2- Boy Vs T IA r ,- - City/State/Zip: VA. \A Q t 0 bo Phone.#: - ' k . (3 a I q 4( Are you an employer? Check the appropriate box: Type of project (required): • 1. CI I am a employer with 4. 0 I am a general contractor and I r _..., 6. i_j New construction have hired the sub-contractors employees (fall and/or part-time).* listed on the attached sheet 7. El Remodelin.g 2.. LZ I am a sole proprietor or partner- These sub-contractors have ship and have no employees 8 . 0 Demolition employees and have workers' working for me in any cap 9 0 Building a.ddition comp.i [Ni workers' comp. insurance _ nsurance.T_ 10.0 Electrical repa.irs or additions 5. 0 We are a corporation and its 3. 0 I am a homeowner doing all work officers have4xercised their t 11.0 Plumbing 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 13.0 Other eniployees. No workers' comp- al =ranee 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 affida indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contract= 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 camp policy number. lam an employer that is providr:ng workers' compensation insurance for my employees Below is the policy andjob site information. Insurance Company Name: • Policy # or Self-Ms. 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 imp of critain41 penalties of a fine up to $130000 and/or one-year imprisonment, as well as civil penalties in the form of g STOP WORK ORDER and a fine of up to $25000 a day against the violator. Be advised 'that a copy of this statement may be forwarded to the 01E6 of tieations Of the DIA for insurance coverage verification. / do hereby certify under the paws and penalties o , erjury that the infonnationpr ovided ova_ 1 e_and_rorrrer, _ _ &nature: 1. (-• 1 3 Datz- , 1 - Phone #: - . 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): - I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other ff- , Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : C >T ', L L , �` e — O License Numb r 0•V• \ \ \ I ,--k ycz_ 0 t 0 0 1 (2:2, ) Address Expiration Date �-- 1 03 21 zt 2'16 Signature Telephone $,:.IRealste @4[.. ome"Ir>1t1roveme *Co ltractoCr. s � .,, , r s t a F . , Not Applicable ❑ Company Name Registration N m er 5 cAnAA _A--- l t it Z ( / 70 Address � �j Expiration Date 3 7 ^1� v k- S } k 1� Telephone 2 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. e. 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 'b No ❑ 1 . - .moome Qwne> i 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 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 El Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [D Siding [D] Other [0] I 9 Brief Description of Proposed \ Work: K % \-c) 4L v\ c (AAA oc1 \ 3-e- 4 v" Oo >^f do s -o_. Alteration of existing bedroom "X Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 1 44 fdffii f16iiidi ti on a fitff q tiQUS>ti of iiiifk iii oII6ihtq: 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 L t7 t//� ,4 ._ , as Owner of the subject property / `� hereby authorize t.= V' 1 ( f et v` to act on my behalf, in all matters relative to work au rized by this building permit application. S 2-11 ‘--g-e-C---:-.) of Owner Date I V.�W V /l — , as Owner /Authorized Agent hereby declare that the ateme 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. /1/197 6:7 Print Name . /ice _ ` �✓ e ` fr fJ ✓ 4J Signature of Owner A gent 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 1 = Lot Size I — .: `� Frontage I I -i Setbacks Front imi [x = Side L g_ R ..... , £ L 3 R: f Rear - -' Building Height f i Bldg. Square Footage % [ 1 Open Space Footage % — - - --: (Lot area minus bldg & paved ' parking) _ # of Parking Spaces i '-- __ Fill: ' -.. — (volume & Location) ( - , A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page I and /or Document # ~m _w m B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES Q . IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ,Date Issued C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES I 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton sAq*447!Y¢ } Building Department 212 Main Street m Room 100 :, :• 93 „„-n °,af,41V7ZsArta Northampton, MA 01060 phone 41Z -58.7 - Fax 413 - 587 -1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: (0 C Y C> < wti \ 44 3 . Map ; .. �. Lot Unit K)0 , PA\r■ N^'`' (' t ' f\ 0 O 6 U Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: N 0■.v/ G u � UA V L E Q- ✓ , a%r 3g S' Name (Print) // Current Mailing Address: Telephone Signature �/ 7 Z -” 7 _ 2.2 Authorized Agen • ek, Z 3.t?Y ,-\ KJ 0\°6D Name (Print) Current Mailing Address: � e 2-t7 1 Co 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 ) ® o (b) Estimated Total Cost of Construction from (6) 3. Plumbing L Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 +2 +3 +4 +5) t 5 t © 00 Check Number 5 7 t 92 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings - Date File # BP- 2011 -0328 APPLICANT /CONTACT PERSON ERIC PAYNE ADDRESS/PHONE 32 BURTS PIT RD NORTHAMPTON (413) 218 -4276 Q PROPERTY LOCATION 76 CRESCENT ST UNIT 3C MAP 24D PARCEL 249 001 ZONE URC(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 3 7 skg 6 Typeof Construction: REMODEL KITCHENBEDROOM CLOSET New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 086442 3 sets of Plans / Plot Plan THE FOL NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 Demoliti e a /6 /3 ``' Signature of B lding 0 ficial 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. F 7 J'II aft r BP- 2011 -0328 GIS # COMMONWEALTH OF MASSACHUSE1TS k . i240419. 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- 2011 -0328 Project # JS- 2011- 000539 Est. Cost: $15000.00 ~` " Fee: $90.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ERIC PAYNE 086442 Lot Size(sq. ft.): 19035.72 Owner: MULLER NANCY Zoning: URC(100)/ Applicant: ERIC PAYNE AT: 76 CRESCENT ST UNIT 3C Applicant Address: Phone: Insurance: 32 BURTS PIT RD (413) 218 -4276 () NORTHAMPTONMA01060 ISSUED ON:10/13/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN /BEDROOM CLOSET 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 10/13/2010 0:00:00 $90.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner