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30A-078 Grity of Nazt4antptart L Z � � j>1ria3sRCfficseffs DEPARTMENT OF BUILD0\1G INSPECTIONS INSPECTOR 212 Main Street • Municipal Building '>a Northampton, MA 01060 ,~ s r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to act as i:is/her construction sup,.: ,:nor. 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 backffll), sonotube holes (before pour), a rough buildinL 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 ' a 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeEriblv Name,Business/Organization/Individual): T�i� Address: City/State/Zip: lgore,ti1,6 . 6,41;S 01062 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.F-1 I am a employer with 4. [] I am a general contractor and I mployees(full and/or part-time). * have hired the sub-contractors 6. ❑New construction ;.�am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling hip and have no en�lo;�ees These sub-contractors have g, F-1 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.❑Electrical repairs or additions 3.❑ 1 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.❑Roof repairs insurance required] t _ c. 152, §1(4),and we have no employees. [No workers' 1 Other comp.insurance required.] ---"--".�ri}Tapp roan a c ec ox must a o r out a secnon a ow s owtn err wor ers'co -- "- g mpensanon policy information. t Homeowners who submit this affidavit indicating they aze doing all work and thrn hire outside contractors must submit a now affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors-have employees,they must provide their workers'comp.poficy 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 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. I do hereby rti under the pains an enalties of p rjury that the information provided above is true and corre t Si a e: / Date:Phone#: Official 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: j� Not Applicable ❑ Name of License Holder: �`fc���5 1 �� `t� C 2 cd.)22�2-"- License Number Address ((C�S f j Expiration Date T Signat elephone 9Re6istered t9om provement'•Contrector ;. -- - .-• �_. Not Applicable ❑ Comoa y Name Registration Number Addr-e/1ss,, ,y / Expiration Date Telephone/� le / SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.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...... ❑ I1. HomQaerI- e�nptzaa 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:Per n(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 tw amily dwelling,attached or detached structures accessory to such use and/or farm structures.A verson who constructs re than one home in a two-vear period shall not be considered a homeowner. Such"homeowner"shall submit to the Bui • g Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed un the buildinLy permit. As acting Construction Supervisor your presence 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(Worker Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachus 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 pliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massa usetts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement JMhdows Alteration(s) Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[O] Other[p] Brief Description of Proposed{ � ���� IaJ° 5 U Work: Recta-e) 1911 � 1 LG e X J Alteration of existing bedroom Yes-4 No _ -Adding new-bedroom Yes e \ No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet :Y- «c .:"za i �. »�.;3�""� ,�.:.,,-»�^ »mac-„'n�z,+c.•^. `m' �,ya„y' "� '.,�.t'a"`�-'. "�!. sa_If New house and.orad°ditlon#a exls�rrt4�housing:..complete f`hfortov�inQ: a. Use of building:One Family Icon Two Family Other b. Number of rooms in each fa Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of uction. 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 construction es- - No j. Depth of basement or cellar floor below finis ed grade k. Will building conform to the Building and Zon g regulations? Yes No. I. Septic Tank City Sewer rivate well City water Supply SECTION 7a-OWNER.AUTHORIZATIOR-TQBE OMPLETED=WHEN QWNERS'AGENT OR-CONTRACTORAPPLIES F BUILDING PERMIT I, ( '4-e � (� l u i C as Owner of the subject property 1 hereby authorize 1 I /�t ✓1%e `' S U to act on my behalf, in all matt relative to work authorized by this building permit application. r LZZ, 1112!Mn,14 1 9%®r-1i Signature of Owner Date ap_cw ffAjuthorized Agent hereby da lare t -at 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 Na ign re o O Date ~ _ ' / � Section 4. ZONING All Information-Must Be Completed,Permit Can Be Denied Due To Incomplete Information Existi Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Rear Building Height Bldg.Square Footage % Open Space Footage % #of Parking Spaces (volume&Location) A. Has a Special Perm it/Varia nce/Fi riding ever been issued for/on the site? - ' --' —'-- `~~ _ ----- S date issued:' IF YES: Was the permit recorded at the Registry ofDeeds? NO 0 IF YES: enter Book and/or Document# B. Does the site contain a brook, body of water orwetlands? N DON7KNOVV 0 YES 0 IF YES, has permit been nr need to ba obtained from the Conservation Commission? Needs tobeobta/oed �~� @hto�oed �~� Date �~� v~� ' ' C. Do any signs exist un the property? YES K l NO �r IF YES, describe size, type and location: D. Are there _ hangestnoddonsos�nsin�endedforthopropo� ? YES NO � IF YES, describe size, type and location: E. Will the construction activity disturb(clearing. g�di �g>over 1oc�or�dpo�ofe common p�n that wW|d��rbover 1on�? YES NO |F YES,then oNn�hom�onSmnn Water ManaQm6ent Permit from the DPW iorequired. e rune U E y qorthampton U Bui1 i Departmentrrue eicut~ �:a $�� s 2015 21!21 lain Streetisep va,a f� om 100 e a .. L-----.Northam ton, MA 01060 �; e_s Electric Pnh r phbiie 413-587-1240 Fax 413-587-1272 t?lo#rS f APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY.DWELLING SECTION 1 -SITE INFORMATION This sectron to be completed by office 1.1 Property Address: e61 Map lot Unit R( �t 1 f°c 1,14!,(�i`7 G Zane Overlajr Dratnct Elm S 'mistnct - CB DistncY SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: 1 Name Print Current Mailing Address: ^ ('41 -z> Atw- a4A L-) Telephone Signature 2.2 Authorized Agent: r / Na nt) Current Mailing Address: Gl/� 1 7� ig ure Telephone SECTION 3-ESTIMATED CONSTRUCTION'COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building �`7 V 9C � _-(a)Building Permit Fee 2. Electrical 1/ (b)Estimated Total Cost"of / Construction from 6 3. Plumbing }< Building Permit Fee r 4. Mechanical(HVAC) \� 5. Fire Protection 6. Total=0 +2+3+4+5) � Check Number This Section For 6#16NIl'Use Ohl Date Building Permit Number Issued: Signature: Building Commissioner/Inspector of Buildings Date 4 HIGH MEADOW RD BP-2016-0357 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30A-078 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: vinyl siding BUILDING PERMIT Permit# BP-2016-0357 Project# JS-2016-000571 Est. Cost: $7000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SKYLINE DESIGN 002722 Lot Size(sq. 1): 89733.60 Owner: MURNANE JAMES A&ARLEEN E zoning: URA(100)/WSP(100) Applicant: SKYLINE DESIGN AT. 4 HIGH MEADOW RD Applicant Address: Phone: Insurance: P O Box 60142 (413) 586-8491 FLORENCEMA01062 ISSUED ON.911612015 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE SIDING & ONE REPLACEMENT WINDOW 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 9/16/2015 0:00:00 $60.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner