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43 BAY VIEW AVENUE - BUILDING JACKET 4 3 P�Ay i/ e �W Pno� - - i LEGEND 52"tPNe! ;• moPle d, Overhead Vires —OHW Spot Shot Elevation +12.00 \ s Utility Pole / Deciduous Tree 03 33"E / r"� \ Coniferous Tree �{ApR�JAGEX3lStlt4 \ 24' 4 �f 7��p / / se�5peµ \ // p.+�✓ d�deY° \ 10, low.t / I 1.0 P� 1{ 6 Cfl. ,`\ moal Y�" 01- P mOPle �X \ W HLUL SToril- s \ N a i EXISTING / 2story AREA = 13,584 SF dwelling 33�' 30% ALLOWABLE COVERAGE = 4075 S.F. �! #43 ;.. \ COVERAGE 4024 S.F. (29.60 '{- mapl. q3 ►� \� � / � rel: _ \\ \ �a� 1/Fa,! I peak elev.=45.5' Q��� b9� gave glad0.5' OIQOyO_ 1 � avg. grade 0front=14.3' — ' building height = 26.2' �♦ / IP0,17 x121 �� H pS5 q q q`{I SITE PLAN OF LAND 43 BAY VIEW AVENUE SALEM v PROPERTY OF JAMES A. KLEIN �PEFZ KATHERINE M . KLEIN NOTES: 30 GRAPHIC SCALE SCALE 1 — 10 SEPTEMBER 9, 2011 — ELEVATIONS BASED ON NGVD OF 1929. 10 o s 10 2 'a NORTH SHORE SURVEY CORPORATION 1 U-1 1117-3 14 BROWN STREET — SALEM, MA a inch FEE rt (978) 744-4800 #3615 Yl'OJEGT. KsTn RseTdence Salem, 1'xA Phorlo 603-964-bW DATE: Raw 6e3-964-2MO jiving '5paces, #jnto REVISPD: ARGHITEGTUIUL BHRACES Dw6.NO. 1741 Waahkglon Road ! NH e3Eie - - Certificate No: 778-12 Building Permit No.: 778-12 Commonwealth of Massachusetts City of Salem Building Electrical Mechanical Permits This is to Certify that the RESIDENCE located at Dwelling Type 43 BAY VIEW AVENUEin the CITY OF SALEM — --------------------------------------------------------------------------- --------------------------- ------------------------------------------- Address Town/City Name IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY OCCUPANCY PERMIT FOR(43 BAY VIEW AVENUE) This permit is granted in conformity with the Statutes and ordinances relating thereto,and expires unlesssooner suspended or revoked. Expiration Date Issued On:Tlm May 23, 2013 — � � — GeoTMS®2013 Des Lauriers Municipal Solutions,Inc. ----------------'------------------------------------------------------------ THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) IM ^� L DATA 43 BAY VIE 778-12 Tj8335. USETTS Map e44 t x. Lot 0059 'Category Addition BUILDING PERMIT'Pernwt# 77812, I reject JS 2012,002103 - - Est Cost�$447,0000 00 ' Tee Charged: ' i$3,120.00 '< ""- 1 Balance Due: `$.00 PERMISSION IS HEREB P GRANTED TO: Const.Class: .Contractor: License: Expires: !Use Group: 'Groom Construction CONSTRUCTIOSUPERVISOR-77841 Lot Size(sq. ft.): 11700.216 Owner: James Klein !Zoning: RI— !Units Gained: (Applicant: Groom Construction ;Units Losr.'. - .IAT: 43 BAY VIEW AVENUE �Dlg Safe#: ISSUED ON: 03-Apr-2012 AMENDED ON: EXPIRES ON: 03-Sep-2012 TO PERFORM THE FOLLOWING WORK: REMOVE SIDE ADDITION FROM MAIN HOUSE,BUILD NEW ADDITION&(2) CAR GARAGE AS PER PLANS jbh POST THIS CARD SO IT IS VISIBLE FROM THE STREET �• Gas Plunlbine Buildine Electric Underground: uderground: Underground: .4 ': Excavation: �1 Meter: p '/ { Footings: I2uugh�LA -� ough:llX��,��i7�d"' Roug / r C%•7" /f Foundation: ,V� (Q�' Final: d —��/� FinalCl�;���afJ,6y'�t� Rough Frame: VL �.jj/9.Gi'lj Eked � ` v( Fireplace/Chimney: D.P.W. Fire Health J Insulation: ,� i( Meter: Oil. 1� •• � 1 r Final: kL '512,71;)� {� House Smoke C p,QQ / / Treasmy: Alarm: p�c)� Assessor %Vater: :;;' Final: Sewer: Sprinklers: THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF A. ' OF ITS RULES AND REGULATIONS. Signatu Fee Type: Receipt No: Date Paid: Check No: Amount: BUILDING REC-2012-002322 03-Apr-12 40178 $3,12200 IMPORTANT:O'fiMER OR CON i RACTOR FAUST ARRANGE FOR I'E�iiGCdCI!:,ipECi'10;'tl$DUPING CONSTRUCTION.SEE CURREN 13UiLDl^1G CODE iiaED!i:S✓ECTICNS. _ CALL 978-613-n0a 1 O SCHEDULE AN INSPECTION i i S GeoTMSW 2012 Des lauriers:Municipal Solutions,Inc J ' S tiostm�r., CITY OF SALEM9 MASSACHUSETTS BOARD OF APPEAL 120 WASHINGTON SrREET. 3RD FLOOR a>>;, SALEM, MASSACHUSETTS 01970 TELEPHONE: 978-745-9595 FAX 978-7409846 KIMBERLEY DRISCOLL 1011 FEB - ) A A (L MAYOR r[ V CITY CLERK,SALEM, MASS: February 1, 2012 Decision City of Salem Zoning Board of Appeals Petition of JAMES & KATHERINE KLEIN requesting a Special Permit under Sec. 3.3.5 of the Salem Zoning Ordinance to expand a nonconforming single-family home on the property located at 43 BAY VIEW AVE (R-1 Zoning District). A public hearing on the above Petition was opened on January 18, 2012 pursuant to Mass General Law Ch. 40A, § 11. The hearing was closed on January 18, 2012 with the following Zoning Board of Appeals members present: Annie Harris (acting as chair), Richard Dionne, Jamie Metsch, Jimmy Tsitsinos and Bonnie Belair. Petitioner seeks a Special Permit pursuant to Section 3.3.5 of the City of Salem Zoning Ordinances. Statements of fact: 1. Attorney Scott Grover represented the petitioner at the hearing. 2. In a petition date-stamped November 28, 2011, petitioner requested a Special Permit to allow expansion of the existing, nonconforming single-family house on the property located at 43 Bay View Avenue. 3. At the hearing, numerous residents spoke in support of the project. No one spoke in opposition. The Board of Appeal, after careful consideration of the evidence presented at the public hearing, and after thorough review of the plans and petition submitted, makes the following findings: 1, Desirable relief may be granted, since the project would not be substantially more detrimental than the existing nonconforming structure to the neighborhood. 2. In permitting such change, the Board of Appeals requires certain appropriate conditions and safeguards as rioted below. On the basis of the above findings of fact and all evidence presented at the public hearing including, but not limited to, the Plans, Documents and testimony, the Zoning Board of Appeals concludes: 1. A Special Permit under Section 3.3.5 is granted to construct the addition to the property as shown on the submitted plans. In consideration of the above, the Salem Board of Appeals voted, five (5) in favor (Harris, Metsch, Dionne, Belair and Tsitsinos) and none (0) opposed, to grant petitioner's request fora Variance and Special Permit subject to the following terms, conditions, and safeguards: 1. Petitioner shall comply with all city and state statutes, ordinances, codes and regulations. 2. All construction shall be done as per the plans and dimensions submitted to and approved by the Building Commissioner. 3. All requirements of the Salem Fire Department relative to smoke and fire safety shall be strictly adhered to. 4. Petitioner shall obtain a building permit prior to beginning any construction. 5. Exterior finishes of the new construction shall be in harmony with the existing structure. 6. A Certificate of Occupancy is to be obtained. 7. Petitioner is to obtain approval from any City Board or Commission having jurisdiction including, but not limited to, the Planning Board. 8• Unless this Decision expressly provides otherwise, any zoning relief granted does not empower or authorize the Petitioner to demolish or reconstruct the structure(s) located on the subject property to an extent of more than fifty percent (50%) of its floor area or more than fifty percent (50%) of its replacement cost at the time of destruction. If the structure is demolished by any means to an extent of more than fifty percent (50%) of its replacement cost or more than fifty percent (50%) of its floor area at the time of destruction, it shall not be reconstructed except in conformity with the provisions of the Ordinance. 3 Annie Harris, Salem Board of Appeals A COPY OF THIS DECISION HAS BEEN FILED WITH THE PLANNING BOARD AND THE CITY CLERK Appeal from this decision, if any, shall be made pursuant to Section 17 of the Massachusetts General Laws Chapter 40A, and shall be filed within 20 days of filing of this decision in the office of the City Clerk. Pursuant to the Massachusetts General Laws Chapter 40A, Section 11, the Variance or Special Permit granted herein shall not take effect until a copy of the decision bearing the certificate of the City Clerk has been filed with the Essex South Registry of Deeds. No.z City of Salem Ward Z o - APPLICATION FOR PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION IMPORTANT-Applicant to complete\a1n items in sections:I, II, III, IV,and IX. I. AT(LOCATION) �I J (9 Y VIEW y QV IAC DISTRICT LOCATION (NO.) (STREET) OF BETWEEN AND BUILDING (CROSS MEET) (CROSS MEET) LOT SUBDIVISION LOT BLOCK SIZE 11. TYPE AND COST OF BUILDING -All applicants complete Parts A -D A. TYPE OF IMPROVEMENT D. PROPOSED USE-FOR"DEMOLITION"USE MOST RECENT USE 1 ❑ New building Residential Nonresidential 2 ❑ Addition(If residential,enter number of new 12 PQ One family 18 ❑ Amusement,recreational housing units added,if any,in part D, 13) 19 ❑ Chruch,other religious 13 ❑ Two or more family-Enter number 3 Alteration(See 2 above) of units ....................................................... 20 ❑ Industrial 21 ❑ Parking garage 4 ❑ Repair replacement 14 ❑ Transient hotel,motel,or dormitory- 22 ❑ Service station,repair garage Enter number of units ........................... 5 ❑ Wrecking(It multifamily residential,enter number 23 E] Hospital,institutional of units in building in Part D,13) 15 ❑ Garage 24 ❑ Office,bank,professional 6 ❑ Moving(relocation) 16 ❑ Carport 25 ❑ Public utility 7 ❑ Foundation only - 26 ❑ School,library,other educational 17 ❑ Other-Specify 27 ❑ Stores,mercantile B.OWNERSHIP 28 ❑ Tanks,towers 8 Private(individual,corporation,nonprofit institution,etc.) 29 ❑ Other-Specify 9 ❑ Public(Federal,State,or local government C.COST (Omit cents) Nonresidential-Describe in detail proposed use of buildings,e.g.,food processing plant, machine shop,laundry building at hospital,elementary school,secondary school,college, 10. Cost of improvement .................................. UD ...................... $ 3 V VC! parochial school,parking garage for department store,rental office building,office building . at industrial plant If use of existing building is being changed,enter proposed use. To be installed but not included in the above cost aElectrical........................................................................... ` a b. Plumbing.......................................................................... S c. Heating,air conditioning............................................. d. Other(elevator,etc.)..................................................... 11.TOTAL COST OF IMPROVEMENT 111. SELECTED CHARACTERISTICS OF BUILDING -For new buildings and additions, complete Parts E-L;demolition, complete only Parts J&M,all others skip to IV E. PRINCIPAL TYPE OF FRAME F. PRINCIPAL TYPE OF HEATING FUEL G. TYPE OF SEWAGE DISPOSAL I. TYPE OF MECHANICAL 30 ❑ Masonry(wall bearing) 35 ❑ Gas 40 ❑ Public or private company Will there be central air 31 ❑ Wood frame 36 ❑ Oil 41 ❑ Private(septic tank.etc.) conditioning? 32 ❑ Structural steel 37 ❑ Electricity 44 ❑ Yes 45 ❑ No 33 ❑ Reinforced concrete 38 ❑ Coal H. TYPE OF WATER SUPPLY Will there by an elevator? 34 ❑ Other-Specify 39 ❑ Other-Specify 42 ❑ Public or private company 46 ❑ Yes 47 ❑ No 43 ❑ Private(well,cistern) J.DIMENSIONS M. DEMOLITION OF STRUCTURES: 48. Number of stories ............................................................ as. Total oors,basfast donewrior area, Has Approval from Historical Commission been received all Boors,based o f exterior dimensions ......................................................................... for any structure over fifty(50)years? Yes_ No_ 50. Total land area,sq.n..-................................................... Dig Safe Number K.NUMBER OF OFF-STREET PARKING SPACES Pest Control: HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED? 52. outdoors............................................................................. Yes No L RESIDENTIAL BUILDINGS ONLY Water: 53. Enclosed............................................................................ Electric: Gas: Full.— Sewer: 54. Number of bathrooms DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED Partial ........... BEFORE A PERMIT CAN BE ISSUED. IV. COMPLETE THE FOLLOWING: Historic District? Yes_ No_x_ (If yes, please enclose documentation from Hist. Com.) Conservation Area? Yes_ No-)� (If yes, please enclose Order of Conditions) Has Fire Prevention approved and stamped plans or applications? Yes_ No Is property located in the S.R.A. district? Yes_ No_ Comply with Zoning? Yes-& No_ (If no,enclose Board of Appeal decision) Is lot grandfathered? Yes_ No (if yes,submit documentation/if no,submit Board of Appeal decision) If new construction, has the proper Routing Slip been enclosed? Yes_ No_ 0 Is Architectural Access Board approval required? Yes_ No (If yes,submit documentation) Massachusetts State Contractor License # Salem License# Home Improvement Contractor # Homeowners Exempt form (if applicable) Yes No_ CONSTRUCTION TO BE COMMENCED WITHIN SIX(6) MONTHS OF ISSUANCE OF BUILDING PERMIT If an extension is necessary, please submit CONSTRUCTION IS TO BE COMPLETED BY: in writing to the Inspector of Buildings. V. IDENTIFICATION - To be completed by all applicants Name Mailing address-Number,street,city,add state ZIP Code Tel.No. ,. MA:P C. 43 13/V U)C w rNr-. .Gw /te44 b/17v 6-0r) Owner or Lessee /L/,/N /✓(�°�� y 2. Contractor Builder's License No. 3. Architect or Engineer I hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to make this application as his authorized agent and we agree to conform to all applicable laws of this jurisdiction. Signature of applica Address Application date DO NOT WRITE BELOW THIS LINE VI. VALIDATION Building �� FOR DEPARTMENT USE ONLY Permit number 3 Building Use Group Permit issued 2.0 � Fire Grading Building n� Permit Fee $ - V v Live Loading Certificate of Occupancy $ Approved by: Occupancy Load Drain Tile $ Plan Review Fee $ CQ.� L NO'15P AND Data e) 'N 1,q AS Gv vert fLfp be d r-oov&A4 Gj k iAo ovve lar \VeSraow\ WIfi, C, S,•1.1 e.,11 bc✓�l,�d�l . 71,e- JlJo W no vwAs OLre Se cv -cA our d[- J�e h omen e. (1� w� L �,�l�i L�. 2 a is d16r S p 0 rfi y1 w r a PERMIT TO BE MAILED TO: DATE MAILED: — Construction to be started by: Completed by: VI ZONING PLAN EXAMINERS NOTES DISTRICT USE FRONT YARD SIDE YARD SIDE YARD REAR YARD NOTES SITE OR PLOT PLAN -For Applicant Use 00u(L 51tC��F(C ,�J �9N'T `tn�Le; BcCKc�}>� CL©Srr 1Z llk-uu 3 20 N a � s k Y S Salem Fierce. Depan tment. F.vice Prevention Swceau 48 La4ayette Street Salem, Ma 01970 (508) 745-7777 FIRE DEPARTMENT CERTIFICATE OF APPROVAL FOR BUILDING PERMIT In accordance w.Lth the prov44i.on6 o6 the Ma,64achu.6ett State Buttdtnq Code and .the Salem F4:,ce Code, appti.eati.on i.6 hereby made 4or approval 04 plana and the ti6a1ance o6 a ee4ti4tcate 04 approval 60r a buZedtng permit by the Salem F.41,ce Department. (Re4. Section 113. 3, Ma6.6. State Bldg. Code) Job Location: Lf 3 y U e-L-J Owner/Occupant: W`Al C , �e� '� �/✓✓\ v Elect,cica.l CJYI,tJLaCtOr: Fiore Suppreaai.on ContAactoa: v SZ_gnatu to o4 Applicant: �/ C Phone #: 7yy- ?7vY Add%".6 o4 /7 City or App.P i.cant: 3 r�G�y Town: Approval date: CertL64c4te 04 approvat Z4 hereby granted, on approved ptart6 or aubmittaZ o4 project data Le 6, by the Salem Rice Depaatment. Att ptarw ane approved aote ly 6o-% .ident44.i ca tion o4 type and Zocation o4 4-Z to protection devtce�6 and equZpment. AZe plane a+ce aubjer-t to approvee o4 any other authority havtn_q ,4u4,i,6dieti.on. Upon completion, the appZicant or in6ta2eer(.6) ahatl requeat an Zm6peet4on and/or teat. o4 the 4Z&e proXeeti.on device- and equipment. ( ** FOR ADDITIONAL REQUIREMENTS, SEE REVERSE SIDE ** ) New eonatruetion. Property ZocatGon has no eompt- anee with the provt4tona o4 Chapter. 148, Section 26 C/E, M. G. L. , -tela, lve to the Zn6taea tl on o4 approved 4.i to ataAm devise-. The owner o6 th l4 property .L6 requ Lked to obta in comptaance " a conditLon o4 obtatnZng a Building Pe,=4t. 0 -Property-Zocat4on .ra to comp.ZianCe with the prov4-4tona o6 Chapter 148, Section 26 C/E, M. G. L. Expiration date: Il 7 / 7 o f 9 l G x / S.i.gnatune o4 Fierce 064i.ci,a2 Fee due: under 7, 500 Sq. Ft. )0. 7 , 500 So. Ft. or Za,7 - $25. 00 Form #81 (Rev. !0/90 ) FIRE DEPARTMENT CERTIFICATE OF APPROVAL FOR BUILDING PERMIT r In compliance with the provision of Section 113.5 of the Massachusetts State Building Code, and under guidelines agreed upon by the Salem Bldg. Inspector and the Salem Fire Chief, the applicant for a building permit shall obtain the Certificate of Approval (see reverse side) and stamped plan approval from the Salem Fire Prevention Bureau. Said application and approval is required before a. building permit may be issued. The Massachusetts State Building Code requires compliance approval of the Salem Fire Department, with. reference to provisions of Articles 4 and 12 of the Building Code, the Salem Fire Code, Massachusetts General Laws, and 527 Code of Massachusetts Regulations. The applicant shall submit this application with three (3) sets of plans, drawn in sufficient clarity, to obtain stamped approval of the Salem Fire Department. This applies for all new construction, substantial alterations, change of use and/or occupancy, and any other approvals required by the Massachusetts General Laws, and the Salem Fire Code. Exception: Plans will not be required for structural work when the proposed work to be performed under the building permit Will not, in the opinion of the Building Inspector, require a plan to show the nature and character of the work to be performed. Notice: Plans are normally required for fire suppression systems, fire alarm systems, tank installations, and Fire Code requirements. Under the provisions of Article 22 of the Massachusetts State Building Code, certain proposed projects may not require submission of plans or . complete compliance. with new construction requirements. . In these cases, provisions of Article 229 Appendix. T,; and Tables applicable shall apply. This section shall not, however, supersede. the _... provisions outlined in the Salem Fire Prevention Regulations, Chapter .1489 MGL, or 527 Code of Massachusetts Regulations. All permits for fire code use and/or occupancy shall apply for the entire structure; fire alarm and/or smoke detector installation shall apply to the entire structure based upon current requirements as per Laws and/or Codes, but the existing structure may comply with regulations applicable for existing structures. Notice: Sub-contractors may also be required to file individual applications for a Fire Department Certificate of Approval for the area of their work. Such sub-contractors shall file an Application to Install with the Fire prevention Bureau prior to commencing any work for those areas applicable. Form 81X (10/90) A ZONING PLAN EXAMINERS NOTES DISTRICT USE FRONT YARD SIDE YARD SIDE YARD REAR YARD NOTES SITE OR PLOT PLAN -For Applicant Use A Je CAI's r, D J a t•C. I uRN'rr ` L "rb��E� BcEKCf}SC CLCSrr �1 1 J n 3 I � vOOf N x �J C MS k 2 W;NDJ�.1 Nv:N Jd,i ^a roF al b; a7-Y oily. - _:in;, T1�" 'I // QQQII TYPE r AUL WE MCIel a Lr' AREc 'JNK 'M A razTz,;r: ti C;,FOPG;roi'rLSeCohtru. VI ZONING PLAN EXAMINERS NOTES DISTRICT USE FRONT YARD SIDE YARD SIDE YARD REAR YARD NOTES SITE OR PLOT PLAN •For Applicant Use e< " C1 °QCs��� � DJi)(7 SFfCa,tc° J � I vRN�T L TDiIF' IF-cat C LCS C r CIPP"oval by G W J n l�' k M 1 2 CFnt>Tinh,) IExIS�'inr�S'-t:,D. a 6 93 �, v other 111; '£!VkYi,n,JUZFr,L'aC'.i;�pr:, AL �._F.•`� l ;:'i'�F,�Via�?!1'/I,i l,�,v,�,�TiT�7.:-<:;�V i PLANS.•RE APPROVED SOLELY FOR IDEh!TIFICA"i 101:OF TYPE AND LOCAT;O?i OF FIRE FROTEGF:W! DEViJ."rd. ALL Pirl E' P"OT;'I Kl ,l DEVICES ARf_ JSJECT 7O A FIR, 4FINA!if5i rdtUC;B'r EGTIO"!,f'OCOtviF'LEiECO.`APLI. • �CO'`V SmJ �QJ�2.GI'W S F �1 hf. ?�.� ..;' .COO;: Y� CITY OF SALEM 3UILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please Print G p DATE b�L CYYy R€,2 i I 1 1 3 JOB LOCATION 93 Gft" V) V-1 "12 , / 5� (�dYl� /MA Number Street address Section of Town 'HOMEOWNER —_FMMA-S C- RC-6-7 J (moa) 7yy-870Y (�TPJs3i- Name Home phone Work phone PRESENT MAILING ADDRESS 3 ( N7`J V) j� LJ )WE Ste-Cw\ Vh A- Dl City/Town ' State Lip Code -he current exemption of "homeowners' rias extended to include owner-occupied dwellings of six units or less ana to allow such homeowners to engage an in- dividual for hire who does not possess a license. provided that the owner acts as supervisor. ; State Building Code Section 109. 1 . 1 ) DEFINITION OF HOMEOWNER: Person(s ) who owns a parcel of land on which he/she resides or intends to re- side, on which there is, or is intended to be, a one to six 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 Derformed under the building permit. (Section 109.1 . 1 ) -he unaersigned "homeowner" assumes responsibility for compliance with the State 3uildina code and other applicable codes. by- laws. rules and reouiations. he undersigned "homeowner" certifies that he/she understands the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER 'S SIGNATURE 1. APPROVAL OF BUILDING OFFICIAL OX AA NOTE: -hree family dwellings lod . cubic feet. or larger. will be required to comply with State Building Section 127.0, Construction Control . HOME OWNER ' S EXEMPTION The Code states that: "Any Home Owner performing work for which a building permit is required shall be exempt from the provisions of this section (Section 109. 1 . 1 - Licensing of Construction Supervisors ) ; provided that is a Home Owner engages a person(s ) for hire to do such work , that sucn Home Owner shall act as supervisor." Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for Licensing Construction Supervisors, Section 2. 15) . This lack of aware- ness often results in serious problems , particularly when the Home Owner hires unlicensed persons. In this case your Board cannot proceed against the unlicensed person as it would with licensed Supervisor. The Home Owner acting as supervisor is ultimately responsible. o ensure that the Home Owner is fully aware of his/her responsibilities. many ccrrmunities require. as part of the permit application, that the Home Owner certify that he/she understands the responsibilities of a supervisor. On the last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. �V COMMONWEALTH OF MASSACHUSETTS E� DEMR:MENT OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET games Camooer, BOSTON, MASSACHUSETTS 02111 mm ss,one V0 � WORKERS' COMPENSATION INSURANCE AFFIDAVIT I. -T" C �E (I icenseei permittee) with a principal place of business/residence at: u3 Qay V ifLJ ftyC►y(,4E4 2YLFM� Mk1- 6 4() (City/State/Zip) do hereby certify, under the pains and penalties of perjury, that: ( ] I am an employer providing the following workers' compensation coverage for my employees working on this job. Insurance Company Policy Number ( ] I am a sole proprietor and have no one working for me. ( ] 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation insurance policies: Name of Contractor Insurance Company/Policy Number Name of Contractor Insurance Company/Policy Number Name of Contractor Insurance Company/Policy Number X,I am a homeowner performing all the work myself. NOTE: Please he aware that while bomeowners who employ persons to An maintenance.construction or repair work on a dwelling of not more than three units in whicb the homeowner also resides or on the grounds appurtenant thereto in not generally considered to be employers under the Workers' Compensation Act(GL C. 152.sect. 1(5)),application by a homeowner for a license or permit may evidence the legal status of so employer under the Workers' Compensation Act. 1 understand that a copy of this statement will be forwarded to the Department of Industrial Accidents' Office of Insurance for coverage verification and that failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties consisting of a fine of up to $1500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a fine of$100.00 a day against me. Signed this ��� day of €C (3r2 19 J7 ? �- Licensee ermiaecA- 0 Licensor/Permittor