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036-275 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 ----- - - - - pe ts-in- conjunctionto thebuilding 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 /�11 a /4/ /' 7,3 `; understand the above. .Home owner /residents signature requesting exemption) (Home g q g P ) I will call to schedule all required building inspections necessary for the building permit issued to me. . / —L - -- - --- T ---._ Date __ Address of work location The Commonwealth of Massachusetts ,_ Department of Industrial Accidents 17.41W. ' Office oflnvestiaations 600 Washington Street r = i Boston, MA 02111 `,��� ' www.massgov /dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Address: - City /State /Zip: Phone m: Are you an employer? Check the appropriate box: Type of project (required): `, 1.0 I am a emplo with 4. 0 I am a general contractor and I 6. 0 New construction employees (full and/or part-time).* have hired the sub- contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have . no employees These sub - contractors have g 0 Demolition for me in an capacity. employees and have workers' working Y P ty. 9. 0 BuiZAi g addition [No workers' comp. insurance comp. insurance_ required] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. I am -a -ome __.__.__ __Q_cers have exercised their _ 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 employees. [No workers' 13.0 Other Comp. insurance regtnred. j *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. Iarn 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 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 fine of up to $250.00 a day against the violator: Ike advised that a copy of this °statement maybe forwarded to the OfEceof Investivations of the DIA for insurance coverage verification /do hereby certi.• u e p ' ' . and penalties ofperjury that the information provided _above_is_true_andcorrecG ,� . / f - / f:10 o o w (/g' I .tare: - Date: Phone #: z 17 k,) l " Official sere only. DO tiDi write in this area, — to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle ape): - . I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other . Contact Person: Phone #: , • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 0., Registered Home Improvement - Contractor , . ;,< . 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 ❑ The_curent_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. - Alco be advice(' that i rith ref'rPnrr'tn Chapter 157 (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 putio t — - - - The undersigned "homeowner" c ertifies and assumes responsibility for compliance with the State Building Code, City of Northatnpton Ur t tai= . nr . -5,.. _.1 • - . e • s- Senn -al- Laws- 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. ❑ I Demolition ❑ New Signs [El] Decks [E] Siding [El] Other [D] /Brief Descnp iov of Proposed ` If Work: '/ i / //"�il-� 7'7J � i l7L-- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa_ if Ne■`house and or addition' to'existioq hous no fol]ow nq: 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 stones? 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 , 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. Print Na Si of owner/Agent 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 Setbacks Front Side L.' R: L: .____ R Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume &Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 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 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 0 Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: ffe there any fo Chan es to or a ditions o ST ns lnten cfedf=1Th ro ert ? YES 0 NO 0 YP P g ... 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 Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 4 .. -- X1 0 a ii3epartr entu$e.otifY ' City of Northampton S tatcis €Perm k ii Building Department ut O e way egn - e ,212 Main Street s /S epf&Avari; grit k Room 100 t o f di[a t jt L1 It, r, i Northa pton, MA 01060 T � strtt 't �` tl � phone 413- 587240 Fax 413 - 587 -1272 t�1 tt � �t � v g av t APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Pro .e •dress: This section to be Completed by office // I t, V' 5 e' / M ap Lot Unit ,r., Zone Overlay District F/O _ r St. District CB District SECTION2 -r PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Own of Record: ifYk /y Name (Print) Current Mailing Address: -y °57 Telephone (,Signatw- L 2.2 4 - • rized 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 1. Building d ( (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 — - _ 641, 0-5 6. Total (1 + 2 + 3 + 4 + 5) Check Number This Section Fnr riffir..ifl Use Only Date Building Permit Number- Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2010 -0546 APPLICANT /CONTACT PERSON MATUSON RONALD A & ROBERTA CHINSKY MATUSON ADDRESS /PHONE 88 MAPLE RIDGE RD FLORENCE PROPERTY LOCATION 88 MAPLE RIDGE RD MAP 36 PARCEL 275 001 ZONE SR(100) / /WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out � y �, r �� Fee Paid y R70 Typeof Construction: BLOWN INSULATION INTO ATTIC 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 F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN 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 Demolition Delay ....../K . ...._...c ./' ./2 ' Cl/0.07 ... g 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. 8 ;�P , RiID 4 RD BP-2010-0546 Cils #: _ COMMONWEALTH OF MASSACHUSETTS 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 -0546 Project # JS- 2010 - 000771 Est. Cost: $1200.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Jot Size(sq. ft.): 35632.08 Owner: MATUSON RONALD A & ROBERTA CHINSKY MATUSON Zoning: SR(100) /WSP 11 Applicant: MATUSON RONALD A & ROBERTA CHINSKY MATUSON AT: 88 MAPLE RIDGE RD Applicant Address: Phone: Insurance: 88 MAPLE RIDGE RD FLORENCEMA01062 ISSUED ON:11/20/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:BLOWN INSULATION INTO ATTIC 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 11/20/2009 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo