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38B-246 (2) LzIu Vf 'Nort4alliptnz z z �839dC�3ISCfi9 �T� DEPARTMENT OF BUILDLj'G INSPECTIONS INSPECTOR 212 Main Street • Municipal Building ,V North,unpton, MA 01060 HONTE OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act a� I.is/her construction sups_ . ;or. 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 any 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 back-fill). sonotube holes (before pour). a rouzh building inspection(before work is cancealed), i-n-sulation inspection (if required) and.a_fnal_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, 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. y Date Address of work Iocation The Commonwealth oflblassachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston,ALA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leably Name(Business/Organization/Individual): Pro ���`r e.. W1,/ Address: City/State/Zip: - Phone.#: W3 5,5p -3/ 1/3 Are you an employer?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 employees(frill and/or part-time).* have hired the sub-contractors 2., I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling ship and have no employees These sub-contractors have g. EJ Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp. insurance.: required.] 5. F1 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption'per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp.insurance required.] - ?ciy ap icon c ec nox must also rill 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 urdicatin-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 emplovees- If the sub-contractors have employ=,they must provide their workers'comp.policy number. lam 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 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$250.00 a day against the tiZolator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under of perjury that the information provided above is true and correct. - .1hepainsandpenddes r Signature` -— -- T J j Phone#: 5- Lonly. Lo not write in this area,to be completed by city or town officiaL n: Permit/License hority(circle one): Health 2.Building Department 3. City/Town CIerk 4.Electrical Inspector 5.Plumbin;Inspector son: Phone#: SECTION 8-CONSTRUCTION,SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone >. -&R g-Rdbilsteted`11+6 15 in _,- - Not Applicable ❑ Company Name Registration Number Fri vv 111,5"0 p 1")� Address Expiration Date Telephone SECTION 10=WORKERS!COMPENSATION,INSURANCE AFFIDAVIT(M-G L..c-1;'52,&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...... ❑ Mp 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-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 buildine 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) E] Roofing ❑ Or Doors elk I Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [L7 Siding [[3j Other[Oj Brief Description of Proposed,) /� / Work: �'�irl !�%l✓�L cv %lI / t`0,- Aiferation o existing bedi ccm Yes No -Adding newtedroom Yes No Attached Narrative Renovating unfinished basement Yes —No Plans Attached Roll -Sheet sa !F Nev °� use rld ot-=addltidii- a ezlstinc ltOus i:tc wthol& heed d fays 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 o. s cons c ion wi i 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`COMPLE-TED WHEx OWNERS AGENT OR,CONTRACTOR APPLIES FOR:-Bf11LDING:PERMIT I, 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 I, 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 Linder 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 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? NE) € 1 E)GNnF v nr YES � ------------ IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW © YES 0 IF YES: enter Book ! Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 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 ® Date Issued: C. Do any signs exist on the property? YES ® NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO 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 NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton nStatuso rm � ' ;Building Department ewavf I � µ -Z�12 Main Street epi, \n Room 100afer?�{leltAsaabE - rtha7.joton, MA 01060 uuo Sets o€Stra faP!'ans �a z plZa er -587-124Q Fax 413-587-1272 R, � g � 7ttle 'SP ee - r APPLJCATIOI�t,TQ CtjIVST{rsl Z,ALT�R,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING f SECTION.: -SITE INFORMATION 1.1 Property Address: rata 6e camprefecf61r off[E> This ectta _ --► �� Caps� dot - ���� ld 0'(� 'OveslagDr / sfs}ct U sa~ot� c> �a,st + SECTION4 2-PROPERTY OWNERSHIPIALITHORIZEUr AGE4T 2.1 Owner of Record: /Lit' Name(P t) Current Mailing Address: T Telephone Signdture 2.2 Authoriz Lent: Name(Print) C Current Mailing Address: X0 Signature Telephone SECTION;3-ESTIMATEff CONSTRUCTION!COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building :4y Building,Permit Fee 2. Electrical .jb};Estimated Totat Cost-of Construction:from 6 3. Plumbing 'Building_Permit.Fee 0 4. Mechanical(HVAC) 5. Fire Protection 6. Total =(1 +2+3+4+5) (�pd - _ -Check Number zvo " This Sectiom For O#i Use Only - Da`Ce Building Permif Number.- Issued: Signature: Building Commissioner/Inspector of Buildings, Date III � i ' f BP-2008-0325 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) CategoryL BUILDING PERMIT Permit# BP-2008-0325 Project# JS-2008-000465 Est. Cost: $5000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PRO-LINE WINDOWS 145077 Lot Size(sq. ft.): 7666.56 Owner: G&S SANDLER AQUISITIONS LLC Zoning: URB Applicant: PRO-LINE WINDOWS AT. 3 OLIVE ST Applicant Address: Phone: Insurance: 191 IRENE ST (413) 552-3143 O CHICOPEEMA01020 ISSUED ON.912512007 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 6 REPLACEMENT WINDOWS & 1 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 9/25/2007 0:00:00 $25.00MO 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 3 OLIVE ST BP-2008-0325 GIs#: COMMONWEALTH OF MASSACHUSETTS Map Block: 38B- 246 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Catep,ory: BUILDING PERMIT Permit# BP-2008-0325 Project# JS-2008-000465 Est. Cost: $5000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Ilse Group_ PRO-LINE WINDOWS 145077 Lot Size(sq. ft.): 7666.56 Owner: G&S SANDLER AOUISITIONS LLC Zoning: URB Applicant: PRO-LINE WINDOWS Applicant Address: Phone: Insurance: 191 IRENE ST (413)552-3143 CHICOPEEMA01020 ISSUED ON.9/25/2007 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 6 REPLACEMENT WINDOWS & 1 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: Insul--tion: Final: Smoke: Final:Q r 10- a a-P 7—1644V THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA N OF ANY OF ITS RULES AND REGU IONS. Certificate of Occu anc Signature: FeeType: Date aid: Amount: Building 9/25/2007 0:00:00 $25.00MO 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo