42-035 rA��—� ' "" ' BP- 2010 -0948
GIs #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 ?ERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0948
Project # JS- 2010- 001407
Est. Cost: $875.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES DAWSON 002701
Lot Size(sq. ft.): 30361.32 Owner: FRADKIN DAVID L & JOAN ROBB
Zoning: SR(100) //WSP II Applicant JAMES DAWSON
AT. 735 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
P O BOX 121 (413) 296 -4710 (�
CHESTERFIELDMA01012 ISSUED ON :412812010 0:00:00
TO PERFORM THE FOLLOWING WORK.- REPAIR VALLEYS & AROUND CHIMNEY
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 4/28/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
City of Northampton s ,
Building Department
212 Main Street
Room 100
Northampton, MA 01060
AP hpn 4 9 -1240 Fax 413 - 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - S.ITE'!INFORMATION
__
1.1 Property Address This section to be completed by office
t -
Map Lot Unit
Zone _ Overlay Distinct
tip
,E1rW --St Dlstr1¢t CB District
.SECTION! 2 - PROPERTY "OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: _
- - Cunt M a il ing F 10� y� o 10 o o L
Name (Print) � g
Telephone
Signature
2.2 Authorized Auenj
A d Z
Name (Print) Current Mailing Address:
nature TelipAone
---
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
7S'
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) 3 � " v v
5. Fire Protection
6. Total = 0 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Onl
Date
Building Permit Number: Issued:
Signature:
Buildng Commissionerllnspectorof Buildings - Date
A
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:L—J R:L--? L:L------J R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg & paved
pairking)
of Parking Sp aces
Fill:
L (volume & Location)
A. Has a Special Permit /Variance /Finding eve een issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the R gistry of Dee 7
NO _0 DON7 KNOW YE 0
IF YES: enter Book Pagel and/or Document #�'
B. Does the site contain a brook, body f water or wetlands? NO DON7 KNOW 0 YES 0
IF YES, has a permit been or ne d to be obtained from the Conserva *on Commission?
Needs to be obtained Q Obtained 0 Date ued:
C. Do any signs exist on the prop;" rty7 YES NO
IF YES, describe size, type =and location:
- fo
f1fii ? Y 0 NO 0
—_7
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 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 O 1 �K
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [O] Other [L7]
Brief Description of Proposed
Work: /Z an 122
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a t jr i a> t i' ai �I rcr a i n e + i ► �� e :
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 foo f new construction. Dim ons
e. Number of stories?
f. Method of heating? replaces or Woodstoves Number of each
g. Energy Conservation Compliance. check Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlan Yes No. Is construction ' hin 100 yr. floodplain Yes No
j. Depth of basement or cellar fl elow finished grade
nfo
k. Will building co a 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 BUILDING PERMIT
J (� IJ �� 1��Z V1 as Owner of the subject
property
hereby authorize w
to act on my behaVin all ers relative to work authorized by this building permit application.
e fry
Signature of Owner rA1 Date
I, 'J✓3 m t/$ 0/961 J 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
SKJnature of Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES I
8.1 Licensed Construction Superv �y _ ) Not Applicable ❑
Name of License Holder : �'VY �'' i� I / J ��`—' 2! 0
License Number
`
Address Expiration Date
Q&!� &�� (
gnature Telephone
BRdeistered Flatn "Iiraveriieib'tcfa .. ;.:K ....;= Not Applicable l
Company Name Registration Number
Address Expiration Date
Telephone //� ' <
SE CTION 10- WORKER 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.
Signed Affidavit Attached Yes....... ❑ No...... ❑
WNW n
'E
The—current—exemption for "homeo±ners" was xtended to mclude_ occupied Dwellines 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 -vear period shall not be c onsidered 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 pe rmit.
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
Laws-Annotated.
o - amp on r riance ; a e
Homeowner Signature
A
The Commonwealth of Massachusetts
Department oflndustrial Accidents '
Office of Investigations
a �L� 600 Washington Street
11 Boston, MA 02111
www.mass gov/dia
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers
APPUcant Information Please Print L �'bl
Name ( Business /Orgmization/Individual): _ //ham Cib� /G1J L1/ l cx
Address: fG
City /State/Zip: C ke5 - fet,,L-
j e, 2Z A01 Phone. #: 2 d
Are you an employer?. Check the appropriate box: Type of project (required):
1.0 I am a employer with 4.. Ej I am a general contractor and I
employees (full and/or part-time).
* have hired the sub - contractors 6. 0 New construction
2.9 I am a sole proprietor or partner- listed on the attached sheet. 7. (] Remodeling
ship' and have a employees These sub - contractors have. .8. Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' comp. insuance comp...ins nce .t
required:] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I -am- a -homeo-waer - -dein i;-all] w - - -- officers have ers d their — -1 1?Iu nub' repairs . er-1F -�- mg -ep ' or additions
myself [No workers' comp. right of exemption per MGL 12.� repairs
insuran required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.].
'Any applicant -that checks box #.1 must also fin out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit.indicating they are doing an work and then hire outside cotntrxtors must subinit anew affidavit indicating such.
tContrwwrs that check this box must.attached an additional shect sbowing the name of the sub_ contractors and state whether or not those entities have
employees. if the subcontractors have employees, they must .pnmde their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
in ormation.
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address:
City/state/zip.
Attach a copy of the workers" compensation policy, declaration page (showing the policy number and expiration date).
Failure to secure coverage: as required under Section - 25A ofMGL c. 152 can lead to the imposition of criminal penalties ofa
fine up to $1,500.00 and/or one impris 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. 15e advised that a copy of this statement maybe forwarded to the Office of
Investieations of the DIA for f sus ance coveraee verification
I do herebY,certify under the pains and penalties ofpedury.that the informdtionprovided_ahove ittrue�azrdcarrect -T
Signature: i /.t /41 Tate• 4 7
Phone #: �r� i �' ��/ G)
Offuial use only. Do not wrrte in flits area, to be completed y eily 0r town orzr L
__City or Town: PermitUcense #
Issuing Authority (circle one):
- =f. Board of Health 2. Building Department 3. City/T Clerk .4. Electrica Inspector 5. Plumbing Inspector
6. Other
- y
Contact Person: Phone #-