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17C-088 (2) i 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 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 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 w location The Commonwealth of Massachusetts P _ Department of Industrial Accidents ' Office bf In vestigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: S City/State/Zip: ' 26:��e_ 0 Phone#: (j' 5K— ?fo�) Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.: 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing all work 11.❑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.] *Any applicant that checks box#I 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 employees. 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 fne nP 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. I do hereby ce r ai s and penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: ( �j— � COL-) OffFcial use only. Do not write in this area,to be completed by city or town 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 App1liicaabllee1,❑.(rQ� Name of License Holder: F3 License N mber Address Expiration Date }'3 --!S`f —2c Signature Telephone 9.Registered Hame.lm`rouemerit Coritracfior ;,. ., w. .' Not Applicable ❑ 2 Company Name Registrdttion Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GL.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....... I!K No...... ❑ 11. Ome;owner.. xem1 1011 The current exemption for"homeowners"was extended to include Owner-occupied Dwellin �(I) wo(2)families and to allow such homeowner to engage an individual for hire who does not possess a li e,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 h lshresides 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,gar"a form acceptable to,the Building Official,that he/she shall be responsible for all such work performed sunder t4 , uilding tdrmit, As acting Construction Supervisor your pi-90KCe on the job site will be required from time to time,during and upon completion of the work for which this pe it is issued. Also be advised that with reference hapter 152(Workers'Compensation) and Chapter*153(Liability of Erhployers to Employees for injuries not res ' g in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work f you under this permit. . The undersigned"ho caner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordi ces, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature ,r %. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) (VI Roofing ED Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding[0] Other[p] Brief Description of Proposed R��.�� �t� f O( Work: no,_ ` r-1 Uyy1 {, Alteration of existing bedroom Yes /Iqo-'�) Adding new bedroom Yes Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition.to eAsting'housing, complete-the 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 1 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basem or cellar floor below finished grade k. Will buildi 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 I MuNea L. as Owner of the subject property ff hereby authorize 1--6 la11 to a on behalf, in all matters relative to work authorized by this building permit ap licatio . Signature wner____ __ ___ --_---,--_--- _._ _ __ _____Date CIQ 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. VA49V- Print Name Signature of Owner/ en 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 t_ �l1 ._ .,.,....,., ; Lot Size ,.. ._.. ...._.. ,._,"____ , �_ ...,....,.."" .. .... .._...... Frontage _. .' ...._., . ..., __. .... ..,.. _,,, .., Setbacks Front Side L:? .._, R.... L: _ ._f R:,-,-- ..' _..__ .." Rear Building Height fM 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? NO 0 DONT KNOW YES 0 I IF YES, date issued:` IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES IF YES: enter Book Page: and/or Document#! B. Does the site contain a brook, body of water or wetlands? NO 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 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 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 0 NO 1 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use oily G " Northampton !tY of p Status a�errlt Building Department Curb Cut Dnveay Perxntl M \ A 212 Main Street SO—h5ept#c ara abtlty a­77 Room 100 vua#eriNeJI A - :, `0hampton, MA 01060 Twa��isz�fstru CP1ans � �� NNIII hdn�413-587-140 Fix 413-587-1272 i iY�le�Jens ' �` OtJ�er Speafy 3 APPLI)CATION 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 10 tP Cffe$fiN Or S-r Map: Lot Unit Fi Oggo')ce / 01062, Zone Overlay District 'Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: mayattj Conlea� ?e.Kl� 1M Gf u .�1C N e Pr t) Current Mailing Address: ' Telephone Sign tur 2.2 Au orized A e t: RD aQQce Name P t) Current Mailing Address: Signal-0-re- Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building > , "f�000 (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=0 +2+3+4+5) w 4COO Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2010-0023 APPLICANT/CONTACT PERSON EDWIN OLANDER ADDRESS/PHONE 97 CHESTNUT ST FLORENCE (413)695-5580 Q PROPERTY LOCATION 106 CHESTNUT ST MAP 17C PARCEL 088 001 ZONE URB(l00)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid T_ypeof Construction:_REPAIR FRONT PORCH New Construction Non Structural interior renovations Addition to Existing_ Accessory Structure Building Plans Included: Owner/Statement or License 049348 3 sets of Plans/Plot Plan THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9RMATION PRESENTED: Approved 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 Pemiit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolitio Delay Z Signature of Building Official 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. ,.� ST BP-2010-0023 GIs#: COMMONWEALTH OF MASSACHUSETTS B ock:17C-088 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-2010-0023 Project# JS-2010-000032 Est. Cost: $4000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group EDWIN OLANDER 049348 Lot Size(sq.ft.): 10759.32 Owner: MCINERNEY TAKLA A&MAUREEN CONROY Zoning URB(100)/ Applicant: EDWIN OLANDER AT. 106 CHESTNUT ST Applicant Address: Phone: Insurance: 97 CHESTNUT ST (413) 695-5580 0 FLORENCEMA01062 ISSUED ON.71812009 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIR FRONT PORCH 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 7/8/2009 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo