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31B-073 (2) 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 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 Date Address of work location . . . The Commonwealth of Massachusetts ,,,.... — Department of Industrial Accidents . Office of Investigations . - ......,.. ...... .. .s.• a s mrla 7.. 600 Washington Street • ., i—:- ...# .: - — Boston, MA 02111 -t,...----E--,,,, . www.mass.gov/dia . -Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/plumbers Applicant Information Please Print Leiiblv Name pusinesorganization5ndividuaD: • - Address: ,- • . City/State/Zip: - Phone.#: . , Are you an employer? Check the appropriate box: . •Type of project (required): / 1. 0 I am a employer with 4 . 0 I am a general contractor and I ,..-, . . 6. i_ j New construction have hired the sub-contractors ‘ employees (fall and/or part-time).* 2. ....,A.h am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and These sub-contractors have. r..o. 3.1oyees .8.Mbemolition . working for me m any capacity. e4 haVe wcirkers' 9. 0 Building' aeon [No workers' comp. insurance 10.0 - Electrical repairs or additions , . 5. 0 We are a corporation an.d its 3.0 I am a homeowner doing all work officers havetrercised their . 11.0 Plumbing repairs or additions • myself [No workers' comp. 'jet Of exemption per MGL 12.0 Rnof repairs . ) • insurance required.] t ' c. 152, §1(4), and we have no 13.0 Other /lieu/ forC4 es employees. [No workers' - comp. insurance required.1 . *Any applicant that checks box #1 must also fill out the section below showing their woticers' compensation policy infonnation. , . . t Homeowneri . who submit thii afftdaVit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-c.ontractors and state witetheror notthose entities have employees. If the sub-contractors have employeeS, they must provide their workers comp policy nmmber. - lam an employer that is providing workers' compensation insurance for my einployees. Below i s the policy and job site information. . Insurance Company Name: . • ' • - • - Policy # or Self-ins. Lic. #: Expiration Date: . . . Job Site Address: - City/State/Zip • ' 1 - Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requited Miler Sectibif 25A 'of19IGL c. 152 can lead the in:Position of dining penalties of a fine up to S1,500.00 and/or one-year imprisonment, as well as cry' il penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a *against tlie violator. Be advised that a copy of this statement may be forwarded to the Office of HifeitigitionsOf the DIA for iiituiinCe Coverize Ida lieli:cby7:CCT_ under thluzs .andp altrsolpirjray that the irtformatiOnprov" o .e — Signature. ' ' / ....--;'' Diii: 0 0 .. -- Phone . Ii: P C; lifiT J - . ' . 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. Electricaljnspector 5. Plumbing Inspector 6. Other , f. . . Contact Person: Phone #: SECTION 8 - -- CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : C � 0 �� e'" 5 q` bl7/ License N ber _/. 7 /et: ,j 1 P5t ,// � /P- l v // Add Expira on Dat / Signature Telephone 9 P 6 _ ' 4: `v: .� ZTTN;. ,11-7..4: Not Ap livable ❑ Company Name < Registrat Num er (57 /7. /el est 7 °4 / //' Addres Expiration D e Telephone DP6 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c.152, §25C(8)) 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 ❑ MAitiiiitthOteitgie 11 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) PO (2.C114 65 New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing El Or Doors [D Accessory Bldg. ❑ Demolition 1■,,i1 New Signs [D] Decks Siding [D] Other [o] Brief De��rigti n of Pr d ld/rCie9s , ' e/5,VI 4(rte eX IsT�N F tXI PI2�NT f O NC � R Work: J Alteration of existing bedroom Yes X No Adding new bedroom Yes No No 5 X2. I Attached Narrative Renovating unfinished basement Yes . No g 5 S i Plans Attached Roll - Sheet �, � �� � � .. �� , � tom. E ��. t� I lAtIS�Fait . : tad ®x i ita .till triple M6I ._ i 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 r _ SECTION 7) ER AUTHORIZATION - TO BE COMPLETED WHEN OW AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I P< A ct M , tie r� , as Owner of the subject property here. - thorize �t, _ e to - .n y behalf, in all m- , - re : tive to work authorized by this building permit - . plication. i - re of • - r Date 1 67e , 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. ` S der eQpaiinnssaand penalties of perjury. i c y " C7(° d ,Z � / ame / �c—/ • J//7� /-n Signature of Own nt 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 1 1 1 1 i Frontage i 1 i Setbacks Front l i E Side L:= = R:i — L:1 R:? £ Rear I . Building Height 1 i I Bldg. Square Footage I 1 I 1% 1 I I Open Space Footage % ( (Lot area minus bldg & paved *, / i I L. 1 i m e . 4 4 parking) # of Parking Spaces R Fill: g (volume & Location) i 11 A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO ,� DONT KNOW 0 YES 0 IF YES, date issued:1 1 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book 1 I Page € and /or Document B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q 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 OD IF YES, describe size, type and location: 1 µ� D. Are there any proposed changes to or additions of signs intended for the property ? . YES 0 NO 6 IF YES, describe size, type and location: 1 E. Will the construction activity disturb (clearing, grading, cavation, 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. c r u sue 'r # -.a wt w ", ; . v im C of Northampton e I i, ; - _ t . - .-- - Building Department - - A :.. 212 Main Street a MA 2 0 2010 Room 100 E Northampton, MA 01060 � s su ,7'7,7-7041F,77,7 , . phone 413 -57 -1240 Fax 413 - 587 -1272 a 1 .r ""J a �. y Tee"" 's 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 Pro. - Ad'ress: r / ,11 : Map , . Lot .; ' Unit / i • 4 L / -zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 7 2.1 Owner of Record: , / - ' °tp/(1 G ' /"/ /" Ve/% ,; • N- e - ri ) / Current Mailing Addressl 414 j // n /1 Telephone / /� , 3 t// ,5 ', i • ature (/j (J c� 2.2 Autho zed An t: 2 4 J /9 / A P , / 0 / 0 7 : 7 7 Name (Print) j Current Mailing Address: e •, e - /7 3 /D C 66 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Offic Use Only completed by permit applicant 1. Building 5` i V ,^ (a) Building Permit Fee 2. Electrical ✓ (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection l 4//7 6. Total = (1 + 2 + 3 + 4 + 5) ,'5 C)i (j Check Number � This Section For Official Use Only Date Building Permit Number: Issued: Signature: �� / j ,S' 7.0/ 16 Building Commissioner /Inspector of Buildings - Date File # BP- 2010 -1038 APPLICANT /CONTACT PERSON ZEKE ROZELL ADDRESS/PHONE 151 NORTH RD WESTFIELD (413) 210 -0300 PROPERTY LOCATION 38 SUMMER ST MAP 31B PARCEL 073 001 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 7 S � Fee Paid S! `� Tvpeof Construction: REBUILD FRONT & REAR PORCHES (SAME FOOTPRINT) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 81717 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: A 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 47-1 t6 Signature of Building 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. 38 SUMMER ST BP- 2010 -1173 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B - 073 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 -1173 Project # JS- 2010 - 001709 Est. Cost: $2500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: _ ZEKE ROZELL 81717 Lot Size(sq. ft.): 13895.64 Owner: LAVELLE ALINE R & TERRENCE M Zoning: URC(100)/ Applicant: ZEKE ROZELL AT: 38 SUMMER ST Applicant Address: Phone: Insurance: 151 NORTH RD (413) 210 -0300 WESTFIELDMA01085 - 9721 ISSUED ON:6/28/2010 0 :00:00 TO PERFORM THE FOLLOWING WORK: CONSTRUCT 4 X 6 FRONT PORCH 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: K,,,,1 /1/47„ ! e 14. THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REG • ONS. 0 gal* 1241114404 Certificate of Occupancy ignature: `"FeeType: Date Paid: Amount: Building 6/28/2010 0:00:00 $50.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo