43-041 B - 2010 -0328
GIS # COMMONWEALTH OF MASSACHUSETTS
.> CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Perrnit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category_ BUILDING PERMIT
Permit # BP- 2010 -0328
Project # JS- 2010- 000450
Est. Cost: $4000.00
Fee: $38.40 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 18382.32 Owner: MARTIN BRUCE S & SOPIE H
Zoning: SR(100) / /WSP II Applicant: MARTIN BRUCE S & SORE H
AT. 58 AUTUMN DR
Applicant Address: Phone: Insurance:
58 AUTUMN DR (413) 584 -2118 0
FLORENCEMA01062 ISSUED ON. 101712009 0:00:00
TO PERFORM THE FOLLOWING WORK.- 12 X 16 SHED
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 10/7/2009 0:00:00 $38.40
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -0328
APPLICANT /CONTACT PERSON MARTIN BRUCE S & SOPIE H
ADDRESS /PHONE 58 AUTUMN DR FLORENCE (413) 584 -2118 Q
PROPERTY LOCATION 58 AUTUMN DR
MAP 43 PARCEL 041 001 ZONE SR(100) //WSP 11
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: ERECT 12 X 16 SHED
New Construction
Non Structural interior renovations
Addition to Existing
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
INFO TION PRESENTED:
proved 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 o Building Official 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.
a
City of Northampton tam
Building Department ,°''
212 Main Streetese
Room 100 la��
Northampton, MA 01060 RN
phone 413 -5UA 240 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
Map Lot Unit
U Co Zone Overlay District
ElrriSt District CB District
SECTION ,2 - PROPERTY'OWNERSHiP /AUTHORIZED AGENT
2.1 Owner of Record
_ _ - - - - - -- - - -- --------------- - --
Name (Print) Current Mailing Address:
Telephone
Signature
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( 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 Irzy 2F
This Section For Official Use Onl
Date
Building Permit Number. Issued:
Signature:
Building Commissioner /Inspectorof Buildings Date
s
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: .__3 R L ~q R J_a_ ~,, W_ .
Rear
Building Height
Bldg. Square Footage
i % -~
Open Space Footage %
(Lot area minus bldg & paved
p arking)
# of Parking Spaces -- _ --
Fill:
(volume & Location) — - -~
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book = Pagel I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES
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:
D � �e there any_proposed cfianges to or a ltions_oi gns intend for the property ? YES NO VV
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 n 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) ❑ Roofing ❑
Or Doors D
Accessory Bldg. Demolition ❑ New Signs [13] Decks [M Siding [0] Other [o]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes _X_ No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
66 If & house <arfrt`or a �tlori= "to.exis #lncr fiousirig,. cot�ipletekt ie:fo fiowip :
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 sto ries?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
L 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 !IVHEN
OWNERS AGENT ;OR CONTRACTOR APPLIES FOR BUILDING 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.
Signature of Owner Date
V1 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.
�rVt
Print Name
Si ature of Owner/As6nt Date
s
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9.° Recistered .HometmproueieatOantracfor ,. , ..,.. 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 exten 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 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 referencerto 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
- - s General -Laws- Annotated.
Northampton urainances Stale o
Homeowner Signature
� R
The Commonwealth of Massachusetts
Department oflndustrial Accidents -
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print LegibIv
Name ( Business /Organza tion/Individual): (
Address: $ V 1A_YYu b r l V
City /State /Zip: Y' _ Phone .#:— a 1- $'-� -al 1 9
Are you an employer? Check the appropriate -box: Type of project (required). _ i
1. [] I am a employer with 4.. E] I am a general contractor and I
employees (full and/or part-time).*
have hired the sub- contractors 6. ❑ New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. � Remodeling
ship and have. no employees These sub - contractors have. .8. [] Demoliition
I
working for mein any capacity. employ a nd have wozkers' 9 Q addition
-. - -
[No workers' comp. insurance camp insurance.
required:] 5. � We are a corporation and its 10.0 Electrical repairs or additions I
officers �ayexezcise d their
11
_ 3. I am- a- Romeo- weer- deing- aR- �verlc- -- - -- -- - ;. - �Plumbingrepaus or additions
myself. [No workers' comp. right of exemption per MGL 12.[] Roof repairs
insurance required) t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.}
"Any applicant that checks box #1- ttntst also fill out the section below showing their workers' compensation policy infomxation.
t Homeowners who submit this affidavit indicating they are doing an 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 = contractors and state wfiether or not those entities have
employees. If the sub - contractors have employees they must.provide their workers' comp.,policy number.
I am an employer that is providing worker' compensation insurance for my employees. Below is the policy and job site
f
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 pave the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the impos rion of criminal penalties of a
fine up to $1 and/or one�year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fix
of up to $250.00 a day against the violator. lye advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I da hereby_certtfy under the pains and penalties of perjury that the information provided above i"rue and - correct
Signature _ _
Date:
Phone #:
L al useonly. Do not wrzte Ln this area, to be complefed by city or fawn Wlc&L
r Town• Permit(License g Authority (circle one):
rd of Health 2. Building Department 3. City/Town Clerk 4. Electrical I nspector 5. Plumbing Inspecto er
ct 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 in sn ct ion n �cess re - wires that the building department be calle to
inspect work at various stages, which include foundation /footings (before backrill),
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
conjunction_to_ the_ building _p -erm itdssued, -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, _br'UIC.e V" 1 lU_ i_L Yl 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
location
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