29-237 228 ACREBROOK DR BP- 2010 -0876
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map :Bloc 29 - 337 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 -0876
Project # JS- 2010- 001298
Est. Cost: $1500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg. ft.): 10018.80 Owner: PURDY MARILYN A C/O RAYMOND F J_ACOBS
r.� ir+ €'n_A, - 0:��'nwcp 4p-nlicant; P : MA P.ILY N A,_C_ /O RAYM F JACOBS
AT: 228 ACREBROOK DR
Applicant Address: Phone: Insurance:
228 ACREBROOK DR (413) 387 -9706
FLORENCEMA01062 ISSUED ON :4/9/2010 0 :00:00
TO PERFORM THE FOLLOWING WORK .-INSTALL FOUNDATION DRAIN PIPE
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:
ra Driveway Final: { ,.
bF�� (,V (� I I �� L€� V,15
Final: f `�.'�. Final: "
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: — - - - -_ _ Insulation:
Final: Smoke: Final: ,V7,S
THIS PERMIT MAY BE REVOKED BY THE CITY OE -NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND
Certificate of Occ
U an 'nature:
FeeType: Date aid: Amount:
Building 4/9/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
r'
's
City of Northampton
O Building Department
'L0 212 Main Street
PQ� Room 100
Northampton, MA 01060
phone 413 =587 -1240 Fax 413 - 587 -1272 "
�x
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address 2 L-�
This section to be completed by office
Map Lot Unit
Zone Overlay Distnct " }
„Eirti St" Distri "ct CB, District
SECTION 2 -PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
�,41e j 4/�',� Ti�C ®�'.(' 2,29 ,� C ��� Orc ��. T� �r�t�l Z
Name (Print) Cup yly Add O�
Telephone
nature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED= CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building ' 0 (aj 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) Check Number i
This Section For Official Use Onl
Building Permit Number: Date
Issued:
Signature: y q l0
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
Frontage
Setbacks Front L--j
Side L: U ._..V.. L: R:
Rear w�
F
Building Height
Bldg. Square Footage % - —
Open Space Footage _ , %
(Lot area minus bldg & paved
par
# 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 Q 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 Q NO Q
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:
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 Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [O] Other [�]
Brief Description of Proposed
Work: �7cC a �f�T e �tr •>h PT !/t07y�a �' , n �Ta i l �f /�� �,' yi �J��%
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa. .lf t�y �t and.bl t d low re is IInc1!n I q:?iGt�
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!-10 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.
Signature of Owner Date
I, AZ4/p d• �ft CO`Jf 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.
, - —A
Print Name
2 0 /0
Sign of ner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
8wl�eaiters€ klomlrrtronnenl Gi<inct#r y 3 �, ._.. ., .' ';' Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION I.Q. WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GiL. 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...... ❑
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 homeown
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 Investigadons
U 600 Washington Street
Boston, MA 02111
www.mass gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Pleas Print Legibly
Name (Business orgmizationdndividual):
Address:
City /Statelzip: Phone. #:
Are you an employer?. Check the appropriate box: Type of project (required) :.
1. ❑ I am a employer with 4.. I am a general contractor and 1 6. ❑ New construction
employees (full and/or part-time). * have hired the sub- contractors
2.. El I am a sole proprietor or partner- listed on the.attached sheet. 7. ❑ ems$ 11
ship � have no employees
These sub - contractors have. .8. ❑ ��on
wor for me m as enIoyees_andhave workers'
king y ty . - - sanrA #_ IIButldmg addition
workers' COTT�7 l�luaIIeC - co �' -
10,
5. E We are a coipoiation and its 0 Electrical repairs or additions
am a homeowner doing aIl work
officers have--- Ewcised their I LEI PIumbing repairs or additions
I .
myself [No workers' comp. right of exemption per MGL 12.[].Roof repairs
insurance required.] t c: 152, § 1(4), and we have no 13.0 Other
employees. (No workers'
comp. insurance required.1
'Any applicant -that eheciz box #T must also fill out the section belowshowing tbeirworkcrs'- corr;msation policy information
t Homeowners who submit tins affdavit.indi=ang they are doingall work and they hoe outside contrxiacs must subuut anew affidavit indicating such:
t r 1 actors that check this box must attached sn additional shed showing the name of the sub- contractors sad state wisether ornottbose entities have
employees. Ythe s conttactots have employees, they must provide their workers' comp. policy number.
f am an employer that isproviding 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 /StateiZip:
Attach a copy of the workers' compensation policy declaration page - (showing the policy number.. and expiration date).
Failure. to secure coverage - as required izndeerr Section 25A'ofMGL 152 can leadto the imposittton of crimm�l penalttes gf a
fine up to $1,500.00 and/or one. -year imprisonment; as well as civil penalties in the form of # 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
Tiivestisations of the I7IA for insurance coverage veitcation _ .
I do'hereby certify under the parns and penalizes o f perjtay that - the informatwn provtdetf ab.org -tm- e- and -iorreri~ —:_
Phone #-
Official use only. Do not write m this area, to be completed by city or town 'officiaL
.City or Town: PermftUcense #
Issuing Authority (circle one):
J. Board of Health 2. Building Department 3. City/Town CIerk .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 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
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 .
ome owner /resid s signature requesting exemption)
I will call to schedule Al required building inspections necessary for the building permit
issued to
Date — /W , 7 8 2-010
Address of work
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