29-342BP-2011-0522
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)
Category:
Permit # BP- 2011 -0522
Project # JS- 2011- 000852
Est. Cost: $2300.00
Fee: $25.00
Const. Class:
Use Group:
Lot Size(sq. ft.): 11979.00
Zoning: URA(100) //WSP
BUILDING PERMIT
PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
RICHARD SCOTT 83108
Owner: NIQUETTE RAYMOND H & JEAN A
Applicant: RICHARD SCOTT
AT: 110 AUSTIN CIR
Applicant Address: Phone: Insurance:
20 BULLARD AVE (413) 533 -6340
HOLYOKEMA01040 ISSUED ON. 121712010 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WOODSTOVE & LINER
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W.
Underground: Service: Meter:
Rough: Rough: House #
Driveway Final:
Final: Final:
Gas: Fire Department
Rough: Oil:
Final: Smoke:
Building Inspector
Footings:
Foundation:
Rough Frame:
Fireplace /Chimney:
Insulation:
Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeTvpe: Date Paid: Amount:
Building 12/7/2010 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
J0 t
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
c^ phone 413- 587 -1240 Fax 413 - 587 -1272
2.2 Authorized Agent:
1. Building
2. Electrical
3. Plumbing
Current Mailing Address:
Telephone
Official Use Only
(a) Building Permit Fee
(b) Estimated Total Cost of
Construction from (6)
Building Permit Fee
4. Mechanical (HVAC) �Q 5 7
5. Fire Protection L �
6. Total= (1+ 2+3+4+5) (7 Check Number
This Section For Official Use Onl
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
r ftl
I Section 4. ZONING I All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued: j
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 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 Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , 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 Q NO Q
IF YES, describe size, type and location:_ _^m
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 Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Existing
Proposed
Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
_
Setbacks Front
Side
Rear-
L:= R: E.. ._..
L R:
k
- - - - -_
Building Height
- --
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
p arkin g)
%
---
# of Parking Spaces
Fill:
volume & Location
--
,
i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued: j
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 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 Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , 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 Q NO Q
IF YES, describe size, type and location:_ _^m
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 Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION:OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [r-3] Decks [Q Siding [lam] Other [
Brief Description of Proposed ,, ,p
Work: �.1. �A U ca �,�1�C� �V ) /� �Cb ✓ E7�/ l__
Alteration of existing bedroom Yes L No Adding new bedroom Yes � No
Attached Narrative Renovating unfinished basement Yes ti 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
i. 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
I SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING 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.
of Owner Date
N/ 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 under the pains and penalties of perjury.
V
Print Name
IN
of Owner /Agent Date
114
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor
Not Applica ❑
Name of License Holder G 0
/�
A �� 1)
' S 1 _
J�j
J ►r
- 2- Z>
t✓ L �L
� L
License Number
6 - ) `J — ) 12
Address
r
Expiration Date
13'
5 ;� Y
Signature Telephone
. Re
Not Applicable ❑
l6 a6`
Regi tration Number
Company Name
Address I
Expiration Date
i og a
e
Telephone
�
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.
Affidavit Attached Yes....... C1 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 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 -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
s
4 The Commonwealth of Massachusetts
Department of Industrial Accidents .
Office of Investigations
600 Washington Street
Boston, MA 02111
' www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers
Name ( Business /Orgmn nfion/lndividual):
Address: f U L L )4 Y
City /State4ap: ) �6 L y tlKe 1�✓� s Phone. #:
Are you an employer ?.Check the appropriate box:
1. ❑ I am a employer with
4._ ❑ I am a general contractor and I
employees (fall and/or part time).*
have hired the sub- contractors
2.. Mfazn a sole proprietor or partner-
listed on the attached sheet
ship and have no =iployees
These sub - contractors have.
working for me in any capacity.
e134 _l0 yees and have workers'
No wflrkCFS' coin: hisunmca
_. comp.- ins ttranr ,-
required ]
5. ❑ We are a corpoiation and its
3. ❑ I am a homeowner doing all work
officers ha a xercised their
myself [No workers' comp.
right of exemption per MGL
insurance required:] t
P. 152, § 1(4), and we have no
employees. [No workers'
comp. insu rance regture&J
Type of project (required):.
6. ❑ New construction
7. ❑ Remodeling
.8. ❑ Demolition
9 Q Sui3dmg addition
10 ❑ Electrical repairs or additions
1 L❑ Plumbing repairs or additions
12.�. Roof repairs
13.❑ Other
muy appucanc •max cnems oox iF1 must also tell out the section belowshowmg theirworkas' compensation policy information:
t Homeowners who submit this affidavit.indicating they are doing an work and then hire outside contractors must submit a new affidavit indicating such.
1 Contractors that check this box must.attached an additional sheet showing the name of the sub- contractms and state whether or not those entities have
employee. If the sub - contractors bive employees, they trust provide their workers' comp-policy nmnber.
I am an employer that is providing workers' compensation insurance for my employees Below is the policy icnd job site
information.
Insurance Company Name:
Policy # or Self-ins. Lic. A
Expiration Date:
Job Site Address: CitylState/Z.ip:
Attach a copy of the workers' compensation policy declaration page "(showing the pglicy number and ezpuation date).
Fa$ure . to secure coverage, as required Under.Secti&n 25A of MGL c: 152' can lead rA 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 STOP WORKORDER 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 0ffi'ce:of
Investrsahons of the DIA for insurance' coverage verifiew on
I do hereby certify under the
p and penalties ofperjury flint the information provided av and- correct__.__
Sit�ature:-. --D a te,
Phonek W� � J �� - —
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
4. Electrical Inspector 5. Plumbing Inspector
Contact Person: Phone #: