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29-319 (2) HOME OWNER EXEINIPTION ACIO�OWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CINIR 108.).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 t::p 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 occupancv 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 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, �? ,- «�- `"`�i ) - i understand the above. (Home owner/resident's signature requ sti b exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location tl,,N 2 Ad CC61 --56� �}(� M A a..t The Conztnonwew%111 of Ilassachmse�zs — Department of lndusrrlalAccidel:Is ©jICe of Investi-arions 600 YT hirtg ton St.eet Boson, MA 02111 wivn�nzass.,ov/dia I,Vorkers' Compensation Insurance Affidavit: Builders/Contractors,'EIectricians,'Plur::bers Aoalicant information Please Print Legibly Name (Business/Organizarionilndividual): Cit,-%Statt/Zip: Phone#: Are you an emplover' Check the appropriate box: Type of project(required): 4. I am a general contractor and I 1.❑ I am a employer with 6. ❑New construction dIffirmployees (full and/or part-time).* have hired the sub-contractors ?. [TI am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working forme in an capacity. employees and have workers" Y 9. ❑Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.� I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [- o workers' comp. right of exemption per MGL 12.7 Roof repairs insurance required.] t c. 1_52, §1(4),and we have no employees. No workers' li.❑ Other comp.insurance required.] *Any applicant that checks bex TI must also fill out the section below showing their workers'compensation policy information. 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 shcwi rg the name of the sub-contractors and state whether or not those entities have employees. If the sub--ontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company dame: Policy T or Self-ins.Lic.#: Expiration Date: Job Site Address: City StateiZip: 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 2fA of\iIGL c. 1f2 can lead to the imposition of criminal penalties of a fine up to S 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DLz for insurance coverage verification. I do hereby certify under the ains nd penalties ofperjury that the information provided above is true and correct- Signature: - r-••7 Date: Phone 0 Jicial use on1y. Do nor wrire in this area, to be completed by city or town oFj'zciaL Cin!or Town: Permit/License Issuing Authority (circle one): 1.Board of Health 2.Building Department 3. CitviTown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone T: SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction SuoerAsor.- Not Applicable ❑ Name of License Holder: License Number ,dcress Expiration Date Signature Telephone I-.Registered Home Imarav6.mertt C•onti-actor w a: M_R :, .-,, Not Applicable ❑ :omoanv Name Registration Number .ddress Expiration Date Telephone ECTION 1:0-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,,§:-25C(6.).) +orkers Compensaion Insurance affidavit must be completed and submitted with this application_ Failure to provide this affidavit will result the denial of the issuance of the building permit. oned 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.CNIR 780. Sixth Edition Section 1083.5.1. 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-vear 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 buildin!permit. As actin-Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of ffie 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 undersizned"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 Si-nature —Y J may^ f _ SECTION 5-DESCRIPTION OP PROPOSED WORK(check all aooiicable) i New House Addition 0 Replacement Windows Alteration(s) C Roofing l Or Doors 0 Accessory Bldg. Demolition 0 New Signs [01 Decks jp Siding jpi OtherfZ!t Erie(Description of Proposed (� t / 1 Work: N S � 1 U1 C1COG I �JC J� ' U UI'(�i��/ CX�?S�A�`' Nf �jCl�J7/It1l� C�C�C6 (�C Alteration of existing bedroom Yes-X No Adding new bedroom Yes —__/ No A-t ached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa If Atew hods:r aini or ai drtion.to ezistina-housina,compile a thdifwidi ho: a. Use of building : Ore Family Two Family Other b- *Nwnber 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 stores? f. Method of heating? Fireplaces or Woedstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 1GO ft. of wetlands? Yes No. Is construction within 100 yr. floodpiain Yes No j. Depth of basement or cellar floor below finished grade k. Wilf building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Pnvate well City water Supply • SECTION 7a OWNER AUTHORIZATION-TUBE COMPLETE)S_WH OWNERS-AGENT OIL CONTRACTOR2 APPLII=S FOR B.EIILDINC PEFR I. as Owner of the subject property hereby authorize to act on my behalf, in ail matters relative to work authorized by this building permit application. Signature of Owner Date MCA(- ' as Owner/Authorzed A.geni hereby declare teat the statements and information on the foregoing application are true and accurate, to the best cf my knowiedge and belief. i Sigred under the pairs and penaities of perjury. i Print i\iarre cr- re-f^wre ^cent - 6-c)q-- 4e ° � ~~ Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Exist,= Proposed Required by Zoning This column to be filled ill by Buildin.g Department L Lot Size o'Sze ..........:� Frontaze Rea Building Height Bldg, Square Footage % —------ Open Space Footage % (Lot area minus bIdg&paved DarldnO of Parkina Spaces (volume&Location) A. Has a Special Pemit/Variance/Finding ever been issued for/on the site? \_� �~� YY »�� �~� NO �� DONTKNO Y�3 �~� IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? �� NO �� DONTKNOYY 0 YES IF YES: enter Book Page and/or Document# ` B. Does the site contain a brook, body uf water orwetlands? NO 0 DONTKNOYY 0 YES 0 IF YES, has permit been or need to be obtained from the Conservation Commission? ' Needs tobeobtaned y—� Obtained �-\ Date � ^ v�� ' \�/ ' C. Do any signs exist on the property?� YES �_/ NO IF YES, describe size, type and location: � D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 IF YES, describe size' type and iocation� / E. Will the construction activity disturb(o| ohng.grading, excavation, or filling)over 1 acre orisit part ofa common pian that will disturb over 1acre? YESy ) NO ���) �� |FYES.�h-(i�'a­No�fi­im-�fchSFo—rm W§������gemdHf'Pehnit from the DPW iorequired, Department use only qT Northampton Status of Permit-. I 11g Department Curb CutlDmrewayPermit 212 Main Street SewerfSeptirc- labtlity 2 20(x °°' Room 100 Water/welrAvailabil North mpton, MA 01060 Two Sets'of Structural Plans _ -- p 49 3-58 -1240 Fax 413-567-1272 Plot/Site Plans ;'k} Other Specify. PPi1CATiON_T.O CONS�'RUCT,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:') .� .4o,r e,6 rbv-� ko M°� Let Unit Zone Overlay District EIM St District CS District SECTION 2-PROPERTY OWNERSHIPIAU "HORIZED AGENT 2.1 Owner of Record: Name(Print)/-14Qr y L, :r KA&J(i1 Ck( Current Mailing Address: f� Telephone Signature 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 (a)Sur7ding'Permit Fee 2. Electrical (b)Estimated Total:Cost of Construction from (6) 3. Plumbing I Building Permit Fee 4. Mechanical(HVAC) �3 5. Fire Protection I 6. Total= (1 +2+3+4-+5) - Check Number '� I This Section For Official'Use Only Date_ Building Permit Number. Issued: Signature: Building,Commissioner/Inspector o .ui mgs �" Date IM 6 File#BP-2008-1171 APPLICANT/CONTACT PERSON JEKANOWSKI ROBERT P&MARY E ADDRESS/PHONE FLORENCE '6y e�- PROPERTY LOCATION 423 ACREBROOK DR MAP 29 PARCEL 319 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INSTALL WOOD PELLET FURNACE New Construction Non Structural interior renovations Addition to Existing Accesso1y Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pprovt 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 5t/­ ",Z",Z, ,04 C-1 Signature of Building Offio6l 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. 423 ACREBROOK DR BP-2008-1171 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-319 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) CateiZiory: BUILDING PERMIT Permit# BP-2008-1171 Project# JS-2008-001726 Est.Cost: $3300.00 Fee: $25.00 PERMISSIC'N IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor__ Lot Size(sq. ft.): 16944.84 Owner: JEKANOWSKI ROBERT P&MARY E Zoning: URA Applicant: JEKANOWSKI ROBERT P & MARY E Applicant Address: Phone: Insurance: (413) 584-4882 O FLORENCEMA01062 ISSUED ON:612612008 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL WOOD PELLET FURNACE 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: Drivewa),Final: Final: Final: i oo, Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: OK 09/17/c� LautS THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy�/-u- (�� Signature: F FeeType• Date Paid: Amount: Building 6/26/2008 0:00:00 $25.004582 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo