11A-022 BP- 2010 -1044
GIs #: COMMONWEALTH OF MASSACHUSETTS
I ,ki'Ii�l 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 -1044
Project # JS- 2010- 001542
Est. Cost: $64500.00
Fee: $387.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY SENEY 061088
Lot Size(sq. ft.): 25395.48 Owner: HELEMS JOHN W SR & KATHRYN G
Zonin URA(100)/ Applicant: TIMOTHY SENEY
AT. 54 UPLAND RD
Applicant Address: Phone: Insurance:
43 COUNTY RD (413) 667 -0230
HUNTINGTONMA01050 ISSUED ON :512112010 0:00:00
TO PERFORM THE FOLLOWING WORK.- KITCHEN & BATH,ADD 3/4 BATH &
REPLACEMENT WINDOWS /DOOR
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 5/21/2010 0:00:00 $387.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -1044
APPLICANT /CONTACT PERSON TIMOTHY SENEY
ADDRESS/PHONE 43 COUNTY RD HUNTINGTON (413) 667 -0230
PROPERTY LOCATION 54 UPLAND RD
MAP 11A PARCEL 022 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: RENO KITCHEN & BATH,ADD 3/4 BATH & REPLACEMENT WINDOWS/DOOR
New Construction
Non Structural interior renovations
Addition to Existin
Accessory Structure
Building Plans Included:
Owner/ Statement or License 061088
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9161ATION 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
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Building bfficial 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.
t
City of Northampton
Building Department
212 Main Street
2 ^010 y Room 100
No hampton, MA 01060
ph04 413- 87 -1240 Fax 413 - 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Proaertv Address ; .
This section to be completed by office
Unit
U Zone Overlay D stnct
Elr i $t; District CB District_`
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (Prin Current Mailing Address:
L!CnJ IYX
Telephone
Signature 49
2.2 Authorized Agent:
Name (Print) j Current Mailing Address:
- Ua 3c
Signature - Telephone
SECTION 3 - ESTIMATED ;CONSTRUCTIONCOSTS
Item Estimated Cost (Dollars) to be Official Use Only
com leted by ermit applicant
1. Building Jd� BOO c. (a) Building Permit Fee
i
2. Electrical(b) Estimated Total Cost of
Construction from 6
3. Plumbing 550 �, Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) G` E5 o Check Number
This Section For Official Use Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspectorof Buildings 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
Lot Size��� w -_
Frontage
Setbacks Front
Side L: R: =_1Z_..j L: L-1QJ R:
Rear��
Building Height
Bldg. Square Footage �,� % --
Open Space Footage %
(Lot area minus bldg & paved 7 t ®.�.
p arkin g)
# of Parking Spaces
Fill: �.
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued: j
A 3
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON 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 ® 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
IF YES, describe size, type and location:
i
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 C)
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTIONS- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [O] Other [DJ
Brief Description of Proposed
Work: .tlkz l /ovio c7tx K /TV!/r� 13'I�TN ill �G ZFL pCSLisTi 3a l
Alteration of existing bedroom Yes D< No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ;
Plans Attached Roll - Sheet
sa "MSlt� iidl ert�itlLi s� ..tli�illnia:
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
SECTION ' -7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR:BU'ILDING PERMIT
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.
SigAat of Owner Date
as OwnerLAL
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 pedury.
Print Name
C)
Signature of Owner /Agent Date
SECTION 8 - EONSTRUCTION`SERVIC'ES
8.1 Licensed Construction Supervisor Not Applicable �0
Name of License Holder
License Number
Address Expiration Date
Signature Telephone / !!
leterd ;.mti�roveline�iEat-clor ..,': Not Applicable ❑
J�v� ` fir �.r-✓ r�� r�lCr�,eiG- i�73�`f
Company Name Registration Number
Address - Expiration Date
Telephone s', a 1 z
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GiL. c.152, § 25C(fi))
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....... JO 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 consid a ho meowner .
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
_ T
The Commonwealth of Massachusetts
Department of Industrial Accidents .
Office of Investig, ations
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): /ii�✓.�� Lrti17z/te7�nJu-
Address: ;
City /Statemp: �.�,,e c.�i s y, - U/Q� o Phone. #: y/3
Are you an employer?. Check the appropriate box:
general contractor and I Type of project (required):
L ❑ I am a employer with 4.- ® I am a g
employees (full and/or part time).* ; have hired the sub- contractors 6 ❑New construction
2. ❑ I aai a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no loyees These subcontractors have. 8 Demolition
working for me in any capacity. emplo_yees_and have wort;:ers'
: 9 II ulding mo audition
[No workers comp'. fimnance - '�• insurance #_
require-11 5. We are a corpoiation and its 10.2 Electrical repairs or additions
3.0 officers havehercised their I am a homeowner doing all work , • 11.EJ Plumbing repairs or additions
myself [No workers' comp. rift. exemption perMGL
12:E].Roofrepairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.[:] Other
comp. insurance required j
`Any applicant that checks box #1 nxist also fin out the section below.showing dicirworloets'- eotapeasatian policy infommott
r Homeowners who submit this affidavit indicating they ate doing all work and then hire outside ' submit must submit a new affidavit indicating such:
:Contractors that check this box must.attaehed an additional sheet showing the name of the sub -cm ciors and state whether ornot those entities have
employees. if the sub- contrac have employees, they must provide their workers' comp- policy number.
lam an employer that is providing workers' compensation vtsurance for. my employees. Below i s the policy and job site
information.
Insurance Company Name: _ici� .✓I
Policy # or Self -ins. Lic. A- 2 00 ,1�_GLJ l 1 • `f Expiration Date: ;V
Job Site Address: C>'
City /Sta&Zap:.
Attach a copy of the workers" compensation policy declaration page'(showing the policy cumber and expiration date).
Fatlure . to secure coverage:as required undo Sealion 25A ofNIGT; e. 152" can lead to the hip osid - 6u of'crimm�l penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties is the form of STOP WORK.O tpER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded -W the Office of
investisatioris of the bIA for insurance covera�c vezfica6on .. ..........
I do hereby,certify under the p -and penalties of perjury thaf - the information provuled.ahoVe r_true_aadcorrer�
Signature: of Mite .f}
Phone # t ' • . —
Official use only. Do not write hi this area, to be completed by city or town offu aL
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 #:
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 your), 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
�ermits 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
Date
Address of work
location
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