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25C-071 (10) City of Northampton , Massachusetts #' DEPARTMENT OF BUILDING INSPECTIONS • 212 Main Street • Municipal Building y Northampton, MA 01060 x } INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 6/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 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 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. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations } 600 Washington Street Boston,MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizatio divtdua Address: P U d x L City/State/Zip: L.� ;r t Phone#: y/`3 l' Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. E] I am a general contractor and I em {fuii and/or part-time). * have hired the sub-contractors 6. El New construction 2.Ell am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. F Demolition working or me in an capacity. employees and have workers' g y p �'• t : 9. ❑ Building addition [No workers' comp.insurance comp.insurance. 10.0 Electrical repairs or additions required.] 5. E] We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. o repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowner;who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such lContractors 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site .in,formation. 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$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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. — 7do hereby certify under the airs and penalties ofperjury that the information provided above is true and correct Si e: Date: Phone -- Official-use only.-Do-not write-in this area to be completed by city or town o f ciaL 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#: J SEGTIDN 8 'GONSTI2UCT10N'S�RVICES; "�� _ _ _ _ _ 8.1 Licensed Construction Supervisor: Not Applicable ❑ cJt_y� tl 'S 1 Name of License Holder: `- License Number Address Expiration Date �-- J L, � � 6 atur Te ephone Ke enu n Not Applicable ❑ I Lz d_ Company Nanie Registration Number _Add sres - Expiration Date Telephone GTION�O�,.�1iVQRlfER��COMPENSAT�01�+1�.NSURANCE�F1Q1k5tl� E���;�'2G(G� � '+ 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 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-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 DESCRIPTI IOF PI20POSEDil1�ORK che'cgk ally icafiie ,Y ; dF`•y' '' '. t •�- Fx-",rq'r'' .a.�.M1'+x- Y. .Y«vi �,^"�' ..? New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding[O] Other[Eq Brief Des k�ry.ption of Proposed _ %,Q Work: 4i PC r in Q` t 57 �^y �e ►n.�;i�1 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 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 L 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 �SEG'LION 7a,�,xOWNER.AU'Ei�[ORIZATION`�7:fi�BCROMP,,�L�'ED ..-E1�1� � , ,F DWNEi2S'r��IGEi'�1T4 R��CD��'i�ACTOAP,.P�IES�OI�'NUl#�D�11'� ,EE�MI'�.. ` ^ _ � s e /1 L n/r C ) _ as Owner of the subject property `. l r hereby authorize to act on ehalf, in all mkttel relative to rk authorized by this building permit application. �S Si nature of Own Date I, I nMu9 - L V C�� as Owner/Authorized Agent here declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belie. -Signest_under_the.pains and penalties of perjury. Lv _ Print Name e er/Agent Date Section 4. ZONING Ali Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by tning This column to be filled in by Building Department Lot Size Frontage ' Setbacks Front Q Side L:= R= L:= R:= 0 Rear 0 Q Building Height Q Bldg.Square Footage Q — Open Space Footage _ (Lot area minus bldg&paved parking) #of Parking Spaces Q Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES Q IF YES, date issued:I IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES IF YES: enter Book Pagelf and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q 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 0 NO 0 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 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 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ity,of Northampton ilding Department �t.212 Main Street 5 2(�;Q , Room 100 DEC Nort ampton, MA 01060 hpne411 7-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTlON�1=SlTEFIFORMATION} � ,. ow 1.1 Property Address: q 2 e; -� ``r !rr:.- v'*,.,.?fmr ` 3..,'. SEGTION�. �PROPERTYOWNERSHIPIAUTEiORIZED AGENT 2.1 Owner of Record: ��an1-cIle /v1� 12 OAr -,IV A16RIHAJPTO/O Name(Print) > Current Mailing Address: MA �? ` /�— 4i3 3Z 0 -r 2 0 8 0106 O Telephone tilfhature 2.2 Authorized Agent: Name(Print) Current Mailing Address: 3,:Fz -ftjrffu-re Telephone -"'Y` 9.-ri `..m�! ,�`'` �`' SECTION�STIMATED GONSTRUCTIW'COSTS-;' Item Estimated Cost(Dollars)to be Dollars ( - Official tlse.Oniy =mac �x completed by ermit applicant 1. Building ;lod A(a)Eitul 2. Electrical bsia�d'Totasa ' x` �X.h:r p5 �^ia..i �{ 3. PlumbingBuildingPerlFee � � ' 4. Mechanical(HVAC) "x � � .r 5. Fire Protection _ rte - 6. Total=0 +2+3+4+5) D 4Gheek,NUmber .n..y,�r�-r �St� -�+F.:.1`�c• k.��.P" 'V.a'-�.�.r4 ^4�v r �. � t "+5,4., 'x-�ex"�J -.�+W-�+L,.�,'t.�,�:,,7 +� - u� k c 7"«.�-�' w,� ..v 3ww-- �. ...5;- "'"fro Bwldrn Perini Number r h d' r t o r issued m�M y t u i i is r x r Nit, 4'' "" � Signature wr�-,«.wf:C. _..�5, .;;.� a •�, r�-�. :,"�'�a ,;.ems"'.'•r- ,A.�-x—e.t��v���;�� x }�r� �.'4��`vr�.,-#.sx rk�y�w5.-�rrk,'�ka `�rr� � �'�t ��. s� `'j`�`E'F •� "s � �+ Bu�Iding Cpmmissioner/tnspector of Butld�ngs�'��^' >~ w 42 DAY AVE BP-2015-0662 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C-071 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categoa: ROOF BUILDING PERMIT Permit# BP-2015-0662 Project# JS-2015-001271 Est.Cost: $20700.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: TIMOTHY J LUCE 100515 Lot Size(sg. ft.): 7318.08 Owner: KAHN DANIELLE J&DENISE A MCKAY Zoning. URB(,100) Applicant. TIMOTHY J LUCE AT. 42 DAY AVE Applicant Address: Phone: Insurance: P O BOX 14 (413) 387-9800 LEEDSMA01053 ISSUED ON:1211512014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL STANDING SEAM METAL 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 12/15/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner