11A-055 BP- 2011 -0002
GIs #: COMMONWEALTH OF MASSACHUSETTS
kj� lock: I IA -055 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: B UILDING PERMIT
Permit# BP- 2011 -0002
Proiect # JS- 2011- 000002
Est. Cost: $6000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MATT WILCOX 075440
Lot Size(sq. ft.): 26920.08 Owner: FOSTER DAVID P & DIANNE M
Zoning: URA(100) Applicant: MATT WILCOX
AT. 17 VILLONE DR
Applicant Address: Phone: Insurance:
7 PORTER ST (413) 665 -8269 WC
SOUTH DEERFIELDMA01373 ON. 71112010 0 :00 :00
TO PERFORM THE FOLLOWING WORK.-STRIP 1 LAYER & SHINGLE ROOF
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 Shmature•
FeeType: Date Paid: Amount:
Building 7/1/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
t
City of Northampton
Building Department
' 212 Main Street
, 100
Northampton, MA 01060
phone 413- 587 -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 Property Address
This section to be completed by office
`? f �; /'c' Map:
Lot Uni
C t
,��.�/), dY ,¢ torte OverlayDlstnct ^
Elm St. District " CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
�awiz /I,,- s r 7 Vt /4
Name (Print) Current Mailing Address:
Telephone �/ `j c y . J G i
Signature
2.2 Authorized Anent: 037
N m Print) r Cu enrntt Nailing Address:
& S ?.
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building (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= (1 +2 +3+4+5) QUO Check Number i
This Section For Official Use Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/inspector of 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
Frontage
Setbacks Front
Side L: R: L.iz L: R:
Rear
Building Height
Bldg. Square Footage % �
Open Space Footage ._ _ _ %
(Lot area minus bldg & paved ? _
p arkin g)
# of Parking Spaces -- -- --
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:' I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book 1 Paget I 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 Obtained , Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
_ ..... ........
._______f
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q
IF YES, describe size, type and location: i _7
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 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 D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [[D] Other [pj
Brief Description of Proposed
Work: /Cy,e -- I-C
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes 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
SECTION Ta - OWNER AUTHORIZATION!- TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
I, as Owner of the subject
property /
hereby authorize G�G ` `d
to act on m ehalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, �� (/l/�/ `d \ 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.
Print Name
Signature of Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder - A W �� ; 7 y - / ,C / G
License N tuber
Address Expir ti to
Signature Telephone
.W- "° :.loM ..sr ,.:�.�� +, Not Applicable ❑
Company Name Re istration Number
Address Expiration Date
Telephone / f,4
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.
Sign ed Affidavit Attached Yes....... 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 buildine 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
U Office of Investigations
600 Washington Street
Boston, MA 02111
Y www.m gov/dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print L i 'blv
Name ( Business /Orgmdzation/Individual): / e' ox
Address:
City /State,(Zip: Sou c y �1,�/r� Phone-#:
Are you an employer? Check the appropriate'box: Type ofgroject (required):_
1. [ I am a employer with !9 4.. E3 I am a general contractor and I 6. ❑New construction
employees (frill and/or part time). * have hired the sub- contractors
2.. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. F1 Remodeling
ship and have no, enployees These sub - contractors have. .8. Q Demolition
working forme m any capacity. Io_yees_and Kaye workers'
9 l3uild addition
[No workgs comp- insurance
required:] 5. E3 We are a corporation and its 10 0 Electrical repairs or additions
3.0 I am a homeowner doing all work
officers have xer' . their I L ] Plumbing repairs or additions
right of exemption per MGL
myself [No workers comp. I2�Roofrepairs
insurance required.] t c. 152, § 1(4)', and we have no
o workers' 13.� Other
employees. [N
comp. insurance required.]
'Any applicant -that checks box #1 must.also fill out the section below showing theirworkers'-compeusation policy information:
t Homeowners who submit this affidavit.mdicating they ats doing all work and th= hire outside contractors mast submit anew affidavit indicating such.
tcontractors that check this box must.attached an additional sheet sbowing the name of the sub-contractors and state whetfieror not those entities have
employees. if the sub_ contractors have employees, they must provide their workers' comp. policy number.
l am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: t� rrS
Policy # or Self-ins. Lic. #: DH T T Expiration Date. / `4 / /j�U
,.((� ;� rt
Job Site Address: / `� �. � . City /StafelZip: �� � i �r 9 0—
i3- Attach a copy of the workers' compensation policy declaration page "(.showing the policy number and expiration date).
Fain a to secure coverage; as requii cd ua i Seaton `25A ''o'f 1VIGL c 15z can 1'eacl to the osition of fi ties of a
nap cruel penal '
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 $250.00 a day against the violator Be advised that a copy of this statement may be forwarded to tin O$ice of
Tiivestsations of the DIA for insurance i;overaec veiificatioii.� '
I do hereby,certrfy under the pains and penafties of perjury that the informadon providedlrbQV� ssrrte_aadcvrrect -:__.
S_ Mare Date /A,0/20
Phone #:
Official use only Do not write in this are to be co '
ff y a, mp by cny or town official
City or Town: PermitUcense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk . 4. Electrical Inspector 5. PIumbing 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 persons) 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
�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 me.
Date
Address of work
location