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36-072 (3) DOME 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 regulations. The inspection process requires that the building department be called to inspect woi vanous s ages,w is i rclad o ' fll1, sonotube holes (before your), 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 untal.t e worms canT[ie msnec�d"" . 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 r I, -�---.rte- understand the above. (Home owner/resident's signatu a requesting exemption)- ---- .---- I will call to ichedule al rl-equirecfGuiild ng inpe-dions necessary for the building permit issued to me. Date Address of work location 7c�s1,�• ;� The Commonwealth of Massachusetts Tai Department of Industrial Accidents Office oflnvestigations ' 600 Washington Street Boston, MA 02111 M� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaiblv NaMe(Business/OrganizatiorAndMdual): _ Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.[1 I am a employer with 4. [] I am a general contractor and I 6. ❑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. E]Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp.insurance comp.insurance.# required.] 5. ❑ We are a corporation and its 10.7 Electrical repairs or additions officers have exercised their 11_ _Plumbing repairs or additions I am a homeowner-doing-all-wark_----_ __._._ e —_ _-- - - ❑ myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs . insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ 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 employee`s. If the sub-contractors 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 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 25A of MGL c. 152 can lead to the imposition of criminal penalties of a frle up to-$1,50000 and/oz-on-e=yearimprisonment---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. Be advised that a copy of this statement may be forwarded to the Office of Investi-ations of the DIA for insurance coverage verification. ;Signature:" hereby certi der the pains d penaltie o erjirry that the information prnvided aLu ve is true area correct. Date: Phone#: 1QFf7cinl use only. Do not write in this area,to be completed by city or town official Citv or Town: - - Permit/License# Issuing Authority(circle one): an�gDepa-r neut 3.Cily)Tuwu Clerl�__.�._T1ectrical Inspector 5.Plumbing Inspector b. Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable Iv' Name of License Holder: License Number Address Expiration Date Signature Telephone 9.,Registered-Home Iniorouemeii#:;Gor{tracfos Not Applicable Gi' Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MG,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-oft-he-wor-k-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 o Massachusetts General-La-wsAnnotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition E:] Replacement Windows Alteration(s) Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[0] Other[D] Brief Description of Proposedi / Work: U'Jd%&tre- V'/./ � � 3 7�iv�' .0 LCD /c�dd i ate 69 - -- Alteration of existing bedroom Yes ✓No Adding new bedroom Yes _t,-' No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa if Nernr ©use:and cir`a ldi#io�t ta-existing houslnA,"coillnpl04 ttie,following: 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 TA-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTORAPPLIES 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 Name �. Signature of Owner/Agent 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 _..._. '4°ate.? +- Frontage Y9fJ _ C Setbacks Front Side L lft ~" R: Rear Building Height Bldg.Square Footage ✓?Sa vt� % 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 DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW 0 YES IF YES: enter Book F Page; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 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 NO IF YES, describe size, type and location D. Are there any proposed changes to or additions of signs intended-for the pro perty? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,e vation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department pse only City of Northampton tars aeen►►t - � Building Department ct)'Kd ew#y'ermtt r w ' `212 Main Street Sea�uerSr�fifi►c- allabrtityf x Room 100 #11TiMIfI Ayiablll + s ,OC9 No*ampton, MA 01060 Twi Sets ofStructuralPians /ph�bne 413-5871240 Fax 413-587-1272 Piot/Sit Plans � Lather Sect + i APPL1CO i4TION TO CfJNSIWCTALTER,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: Y17 v c'S��i�4rr,��c:.t i f�GS/4� Map Lot Unit Zone. Overlay District Elm St.District- CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: -----���4'�•yc� r!�R�uf'C� y�7 u�G:sfhr�-.�.,nf�;;y �'.�o� , �/,f't.GL�, �r1 Name(Print) Current Mailing Address 19 'ees� Telephone Signature T 2.2 Authorized Accent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated-Cost(Dollars)-to-be Official Use Only completed by ermit applicant 1. Building .7��y�, (a)Buitding Permit Fee 2. Electrical (b)EstimatedTotal Cast of Construction from 6. 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Cheek Number _ This Section Foy OciaCC[se Or;l Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date t BP-2010-0019 GIS#: COMMONWEALTH OF MASSACHUSETTS t °etc:36-v72 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-2010-0019 Project# JS-2010-000028 Est.Cost: $7500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 199069.20 Owner: CADORETTE LAURENCE&MARY S Zoning: SR(100)//WP/WSP II Applicant: CADORETTE LAURENCE & MARY S AT. 417 WESTHAMPTON RD Applicant Address: Phone: Insurance: 417 WESTHAMPTON RD (413) 626-5559 O FLORENCEMA01062 ISSUED ON:71712009 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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 7/7/2009 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo