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32C-095 • 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 stale 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 iermits 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 me. Date Address of work location 7 ... ., . ' . The Commonwealth of Massachusetts =1,--=..--,---- Department of Industrial Accidents • Office of Investigations • mu .....tt i 600 Washington Street Boston, MA 02111 . - . www.mass.govidia ' .... -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ) e i l tin bovAci'li • Address: cl 0 Octi< ..S4 . - . City/State/Zip: CI ■.,€ tx c "4. 010 bta Phon.e.#: 91 3 SZP.C Are you an employer? Check the appropriate box: Type Of project (required): l 1.0 I am a employer with 4. D I am a general contractor and I 0 employees (full and/or part-time).* have hired the sub-contractors 6. New construction listed on the attached sheet. 7• 0 Remodeling 2. lA am a sole proprietor or parto.er- ship and have no c..).loyees These sub-contractors have . 8. D Demolition employeesand have workers' • . - working for me in a:ay capacity. 9. 0 Building addition - [No workers' comp-. insurance _ camp. insurance.f__ _ __ _ _ _ _ _ 10.L j Electrical repairs or additions required.] • .- 5. 0 We are a corporation and its • 3. 0 I am a homeowner doing all work officers have xercised their .1 11.E1 Plumbing repairs or additions myself [No workers' conip. lien Of exemption per MGL 12.0 Roof repairs insurance required.] t • c. 152, §1(4), and we have no employees. [No workers' 13.E1 Other comp. insurance required.1 • • *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 1. Homeownera who submit this afradaVit indicating they are doing ail work arid then hire outside contactors must submit a new affidavit indicting 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. In.& sub-contractors have employees, they must provide their workers comp policy number. l am an employer that is providing workers' compensation insurance for my employee & Below is. the policy and job site information. . • . Insurance Company Nante: . - , • . Policy # or Self-ins. Lic. #: Expiration Date: . . . Job Site Address: City/Stafe/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 OfMGL c 152 can lead to the iii giOsitibri of r Penalties of a fine up to 81,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP wow( ORDER. and a fine of up to $250.00 a day against the violator Be advised that a copy of dais statement may be forwarded to the Office of Infeitizations Of the DIA for nismarice Cove Verification. fdo her eb _37 c ertifil n - - ; , ; .- - A e nalties of p erj myth at the information prOvided ".. isiru co rrect.____. . . Si. A - tire: ----- , , at: /-,- 9 I/ o • • ,....0.- - Phone :. "" / S — 5 ti - • • Official use only. Do not write in this area, to be completed by city Ur tow n officiaL City or Town: • Permit/License # Issuing Authority (circle one): .1. 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 : JC 55 Inerriticole 0 0 License Number Address Expiration Date 3 S t °s chi Pa S' •ifeq - Telephone S.: ReaisteredrHciirie :lmt�tovetneirit Contractor d , % kf ,. .„: ,„, . a Z . . ,., ,w.. .._ .., Not Applicable ❑ /34 Company Name Registration Number , Nc3^}y c mc - 1 RV/ Address Expiration Date Cie St r(,Tr etc a Telephone cd C �( �t — 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 ❑ t i Owner. EX en 1110 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) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ED Or Doors J� Accessory Bldg. ❑ Demolition ❑ New Signs [11] Decks [E] Siding [1::1] Other [0] Brief Desnipti9n of Proposed H, Work: K 1Q.Lt St�1�iit (y ( ke. ••Jt f�uvlct l akr.c � �Svlt.'4(e, .slns�yL►j I 1 1 r D Alteration of existing bedroom Yes `""No Adding new bedroom Yes V Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa :IfNcw.liol€ se an or:adc iti�fl:10 l xtst na Et U&fl'_ :ampt te fo[iar np: 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 Nc 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, �� 4 , as Owner of the subject pr6:e y hereby authorize JC 55f !o 1oi e to act on my behalf, in all matters relative to workliuthorized this building permit application. � . //0 Signature of Owner ate I, .140r 1 . l -4c kr ,)=55 �`] , as Owner /Authorized Agent hereby declare that the statements and information t he forgoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. �-� J eSS c ? C`' Print • me J .� J S • nature of Owned' gent D e 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 J t ._... =' Frontage i _ _, 4 Setbacks Front i 1 Side ..� R:! L: R; f Rear i Building Height r fi 1 3 r 4 t " '". Bldg. Square Footage 1 3 Open Space Footage % (Lot area minus bldg & paved L „_ ! . _ parking) # of Parking Spaces __. - Fill: , , (volume & Location) A. Has a Special Permit /Variance /Finding ver been issued for /on the site? NO 0 DONT KNOW 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 l I Page ? and /or Document # B. Does the site contain a brook, body of water or wetlands? NO G DONT KNOW Q YES 0 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 IF YES, describe size, type and location: 3 D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO e v .... IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, ex ion, 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 . .. -i Building Department , DEC 2 $ �0 �0 212 Main Street 1 Room 100 • . �: _. F Northampton, MA 01060 ; ti ffi lg a -3 - - phone 413- 587 -1240 Fax 413- 587 -1272 m.. " t' 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 '� C cvV c' I Map Lot Unit fj uA ,-,r\- it'll Zone " Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: \l-,c✓ k Q . VA t S-VW. c ) ? (C'- Z 4- Name (Pri ) Current Mailing Addre s Telephone Signa re 2.2 Authorized 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. Building q Ce 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 6. Total = (1 + 2 + 3 + 4 + 5) k j . CO Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: /' - / Building Commissioner /Inspector of Buildings Date • BP- 2011 -0594 GIS #: 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- 2011 -0594 Project # JS- 2011- 000958 Est. Cost: $3000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JESSE MONTGOMERY 077410 Lot Size(sq. ft.): 15855.84 Owner: HESTON KARL ROBERT Zoning: URC(100)/ Applicant: JESSE MONTGOMERY AT: 22 CONZ ST Applicant Address: Phone: Insurance: P 0 BOX 329 (413) 585 - 8482 LEEDSMA01053 ISSUED ON:12/29/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS /DOOR 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 12/29/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner