42-124 BP- 2010 -0268
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)
Cate BUILDING PERMIT
Permit # BP- 2010 -0268
Project # JS- 2010- 000343
Est. Cost: $3000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group Homeowner as Contractor
Lot Size(sq. ft.): 37897.20 Owner: STONE PETER A
Zoning: SRO 00) / /WSP II Applicant: STONE PETER A
AT. 150 GLENDALE RD
Applicant Address: Phone: Insurance:
(413) 584 -3220 O
FLORENCEMA01062 ISSUED ON. 911412009 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 16 X 10 DECK
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 9/14/2009 0:00:00 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -0268
APPLICANT /CONTACT PERSON STONE PETER A
ADDRESS /PHONE FLORENCE (413) 584 -3220 Q
PROPERTY LOCATION 150 GLENDALE RD
MAP 42 PARCEL 124 001 ZONE SR(100)HWSP II
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: CONSTRUCT 16 X 10 DECK
New Construction
Non Structural interior renovations
Addition to Existin
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF �MATION 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
260
Signature of Building Official Dat
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.
y 4 ) arentts only
City of Northampton uta�fPerxn �r�
r
Building Department I�re�3
212 Main Street
AN
S � vat
- Room 100 � :
O Northampton, MA 01060
SEP
-S One 413 -587 -1240 Fax 413- 587 -1272
t_ ;.p NS T, 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
S6 v .\atom l e �� Map Lot Unit
O v-e- t, C e- t 010(. 2 Zone Overlay District
Elm'St'District GB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (P ' ) Current Mailin Addrss:
TT e
/ 3 r y^ 3 2 Z O
Telephone
SigiYature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone 1. SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building 3Q om. uo (a) Building Pemit Fee
2. Electrical (b) , Estimated Total Cost of
Construction from 6'
3. Plumbing Building. Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
T
6. Total= (1+2+3+4+5) 30601 0
( ) Check Number
This Section For. Dffcial Use'Onl
_ Date _
Building Permit Number_ Issued:
Signature: -
Building; Commissionedlnspector of Buildings Date
i
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
i
Lot Size 1 15 3 3o ._ _ 115 x
Frontage
Setbacks Front p G p
Side L: f R: �- L R. �_
Rear I2 2 t" 2 2 T
Building Height
Bldg. Square Footage l_° %
Open Space Footage _ % --
(Lot area minus bldg & paved
# of Parking Spaces
Fill: I
(volute & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DON KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 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 DONT KNOW 0 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 NO
IF YES, describe size, type and location:- - -
° " — ffie Pere any proposed c tinges o or a itions o suns intended -for t ►1 property ? YES 0 NO
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 NO
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) E] Roofing Ej
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks LV Siding [0] Other [Q
Brief Description of P�of�os�yd 1 /o
Work: (� t cJC e. c �c 01, 2�. k a. hcx: S e
Alteration of existing bedroom Yes X No Adding new bedroom Yes x N
Attached Narrative Renovating unfinished basement Yes f' No
Plans Attached Roll - Sheet
sa, 3f.New . 6 1 ouse`"and or.:a � tl / ori °to "exrst�rrg <ousing, coiGt�p��te "hefroitouv�ig:
a. Use of building: One Family J` Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached l 5
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 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
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 Naft
21-0 0
Signature of Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Ecpiration Date
Signature Telephone
9 "R A steFed Fl+drnel entGat tr ctos: ., ..; .. _. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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.
Signed Affidavit Attached Yes....... ❑ No...... ❑
The-current-exemption for _ "homeowners" was extended to include_ 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. CAM 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 no 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 p ermit.
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
ort amp on r ina es; a —� s General. <L- aws_Annotated.
Homeowner Signature
Wiz:
The Commonwealth of Massachusetts
Department of In dustrial Accidents
Office of Investigations
_ a 600 Washington Street
Boston, MA 02111
www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print LeaibIv
Name ( Business /Organization/Individual):
Address:
City /State/Zip: Phone - #:
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4.. C] I am a general contractor and I
6. ❑ New construction
employees (fall and/or part- d=).* have hired the sub - contractors
2. ❑ I am sole proprietor or partner- listed on the attached sheet. 7. [] Remodeling
ship and have no loyees These sub - contractors have. 8• ❑ Demolition
working for me in any capacity. employees and have workers' 9. O B uti d� addition
[No workers' co insuran • n """�#
_
required_] 5. [] We are a corporation and its 10.[] Electrical repairs or additions
3. I am a omeo-waer deiag -all work - - - - - -- � ce ,sha xerc their --LI- ElP-l repairs or additions
myself [No workers' comp. right of exemption per MGL 12. [] Roof 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 ED out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit,iadicating-they are doing all work and then hire outside contractors must submit a new affidavit indicating such-
( Contractors that check this box must attached an additional sheet showing the name of the sub-conaactors and state whether or not those entities have
employees. If the sub - contractors have employees, they mustpro their workers' conT..policy number.
lam an employer that is providing workers' compensation insurance for my employees. Below is the polity and job site
� '
Insurance Company Name:
Policy 4 or Self -ins. Lic. ff: Expiration Date:
Job Site Address = City /Stafe /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 of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one =year imprison as well as civil penalties in the form of a STOP WORK ORDER and a finne
of up to $250.00 a day against the violator. to advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA, for insurance coverage verification
ll do . e�r
rtify und er the pains and penalties of perjury
Phone #: -
-Official use only. Do not write in tJhu arena to be completed by city or town affu iaL
City or Town: Per-mit/License #_
Issuing Authority (circle one):
- f. Board of Health 2. Building Department 3. City/TownClerk 4. Electrical :Insp 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
regulat ons The inspection n �oce -s req that the building department be calle 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 _r -esult 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
---------- - - - -pe dts - ice con}unctionnrto_the- bu 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 �Q w he -� 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.
Address of work r
location 1 S a 6 1 <- K