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25C-050 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 • • - t • - '. . • .cess respires 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 - building permitissued, .. 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 �s } = —_ Office of Investigations • 1i ll� b 600 Washington Street r _ Boston, MA 02111 � www.mass. /dia -Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/PIumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): 0 " ( $ d4 `etc be,ii Address: /'S re( /tiy / 2, -. f'/o eirei°`f, x t'2/l✓"•6 2.. City /State/Zip: Phone. #: .5 - if f &''s Are you an employer? Check the appropriate box: •Type of project (required): i' 1. ❑ I am a emplo with 4.. 0 I am a general contractor and I 6. 0 New construction �Ioyees (full and/or part-time).* have hired the sub- contractors 2.10'1 1 am a sole proprietor or partner- listed on the attached sheet. 7. 'Reznodelin a ship .p d have. n emaloyees These sub-contractors have. g. 0 Demolition for me in an capacity. employees and have workers' working Y P ty. 9. ❑ Building addition [No workers' comp. insurance _ conT- inarrrarrce.# required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. Q I am a -homeowner- doing- all -work __ _ - -o ez hay._ x is d their _- 1-1. - lumbingrepairs 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 pmvide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below Ls the policy and job site ormation 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 nu 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 is the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator: le advised that a copy of this statement may be forwarded to the Office' of Investieations of the DIA for insurance coverage verification. _ I do hereby certify under the pains and penalties ofperjury:that the information provided.above is true_ and correct - _ _ Si • ..tare: e k % Da te: ' f' el • Phone #: 5 " � — Official use only. Do not write inth this area, to be completed by city n gfficiaL - City or Town: Permit/License # Issuing Authority (circle one): I: Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical I ' sector 5. Plumbing Ins • ector 6.Other .,- - . Contact Person: Phone #: i. I SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: / Not Applicable ❑ / Name of License Holder : ( A' Vi / 0 'G��� /`` f// �- r 05 6 7-- s gy License Number Address Exp Date C ! Z � Si tale Telephone 9: Regis ter" ed .Home;,improuementtaontiactor` , x k:. .... i Not Applicable ❑ ear rvc-ms /re, c,fecr� 16/ 76/ Company Name (:)/ Registration Number - /t / wc. , /2 -, ) - 7 '77c 11/ - / '2_ t /ij 70/ 0 Address / / --��a `/ Expir tion date Telephone , C� -776 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 ❑ 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 - Ordinan ces; State and Local - .4 _ . • S eral- Laws - Annotated. Homeowner Signature - SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House Addition ❑ Replacement Windows Alteration(s) ! Roofing Ej Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[_] Siding [0] Other [0] Brief Description of Propo et s d ;� °CKj711 fi t / . 'X SCS -s 'd 3 id Ckr- 5a'� psi Work: yeti f'hiAil-t- rcu44/- � 70vv r/ j- ,'c'le, Alteration of existing bedroom Yes Ii' No Adding new bedroom Yes e<''' No Attached Narrative Renovating unfinished basement Yes !i No Plans Attached Roll - Sheet .4 If Ne f lietiso.and oradd`rt onto existif q tiousinq, pletethe bilovving: 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 . 1. 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 // - r% 4 '?" , as Owner of the subject property hereby autho ize C s (fr to act on y •e, - , ' a matters relative to work authofized by this building permit application. tom 1�/ ( 1a9 Sign. ur- of Ow -r . Date v (< (t ' , as Owner /Authorized Agent - - eby declare that thements and information on the foregoing application are true and accurate, to the best of my knowledge and hplief. Signed under the pains and penalties of perjury. Print Na e f/q Signature of efAgent Date 4 • 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 M _ Setbacks Front SideL :._..._.._.__... R ::....,..._ _.... L:_ ._.w R: _ _ . Rear ....._._ Building Height Bldg. Square Footage r - ' % --• Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces - - - - -- Fill: i (volume & Location) __._..._...._..... . . _ _.,. �i — _„.._ ..__... —.. A. Has a Spec "al Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES 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 < and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 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 0 , Date Issued C. Do any signs exist on the property? YES 0 NO er IF YES, describe size, type and location: --- -- -` _ { D: Are there any proposes] r angel to or a rtions of'signs intendecrfoFfFe property ? YES f NO E IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, xcavation, 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. : — A '' ,, ,,,,p:•:,;04,s,,,,,,,,, ,',agfiga.=,..-ittlfgeisio.„,,K,,,..e.7,,,,,,,ti,,,,,,,,<:-.,*„.‘,,,,-,,,,- City of Northampton ,74...L1:43.,, • , ' , , .- - i 1: . r u --- Department :‘,.,' 't4.1 tiptewav L .t, E 1 Main Street „Re,ym,,,,,,tici,rpoi!,- <4`1,;.0.„,„,v; ,,,a.:„. ,,,,,,.. -, ., L ' - ' . - - ------------- : Room 100 ;,:1?-'' ,, ../F542i , VV^ North Mpton, MA 01060 , .,-,4-7r607,- T b ,'0 e' , , ...i:eb , .? ,, i I ) 1., CCT 2o 13--1240 Fax 413-587-1272 aiiitl;:at 7CMICARtt:=!:3;:"„A:,:k,„e'figni ? L /ii. ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FANIILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 22_ 7 S--Xceie- Map Lot Unit ' lane Overlay !District 'Elm St District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ' Name (Print Current Mailing Address v re ' 27 4 C ii2.-.`,..*:';1\-/ -- r 51 h-i, ,t-v / Signature C-4-1 ' 3 j 72-7 - -,L 2.2 Authorized Agent: ----- ( /S / K C #; - 1 , 1"//f/ /ei /Dr , - ',A-zreo 7,, 77. Na dn ,./ _----7, tu( 7 Current Mailing Address: .e..._ Telephone SECTION 3- ESTIMATED CONSTRUCTION COSTS . , Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (/ 7" (r-7 - (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 - - 6 -- 6. Total = (1 + 2 +3 +4 + 5) Check Number _____________. _____ _ - - • - This Sectiori For O fficial Use Only Date Building Permit Number: issued: Signature: . !-- ___ ----Ift314E-- ,..........._...- : et — , : . ring ornraissioner/Inspector of Date File # BP- 2010 -0445 + APPLICANT /CONTACT PERSON C & T CONSTRUCTION ADDRESS /PHONE 15 Fairway Drive FLORENCE (413) 586 -4965 PROPERTY LOCATION 227 NORTH ST MAP 25C PARCEL 050 001 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 «f o-6-- Fee Paid Typeof Construction: UPDATE KITCHEN,CABINETS,COUNTERS & FLR & 2ND FLR BATHROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: O wner/ Stateme o r License 062884 3 sets of Plans / Plot Plan THE F LOWING AC HAS BEE TAKEN ON THIS APPLICATION BASED ON INF 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 / i Z L 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. 227 NORTII ST BP- 2010 -0445 GIS #: COMMONWEALTH OF MASSACHUSETTS Map :Block: 25C - 050 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Pernut: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2010 -0445 Project # JS- 2010- 000562 Est. Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: C & T CONSTRUCTION 062884 Lot Size(sq. ft.): 9583.20 Owner: O'NIELL HEIDI Zoning: URB(100)/ Applicant: C & T CONSTRUCTION AT: 227 NORTH ST Applicant Address: Phone: Insurance: 15 Fairway Drive (413) 586 -4965 FLORENCEMA01062 ISSUED ON :10/23/2009 0:00:00 TO PERFORM THE FOLLOWING WORK :UPDATE KITCHEN,CABINETS,COUNTERS & FLR & 2ND FLR BATHROOM 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 10/23/2009 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo