43-178 395 PARK HILL RD BP- 2010 -0488
GIs #: COMMONWEALTH OF MASSACHUSETTS
MapBloc 43 - 178 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 -0488
Project # JS- 2010- 000670
Est. Cost: $900.00
F $56 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. ft.): 87120.00 Owner: HABER WILLIAM J JR & ANDREA L
Zoning: SR(100) / /WSP 11 Applicant: HABER WILLIAM J JR & ANDREA L
AT: 395 PARK HILL RD
Applicant Address: Phone: Insurance:
395 PARK HILL RD (413) 585 - 0682 O
FLORENCEMA01062 ISSUED ON. 11/6/2009 0 :00 :00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 14 X 20 SHED W/12 X 20 ATT
CARPORT
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: 47j--, CC i5 1 to Leo lS
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy O ('� "ignature:
FeeType: Date Paid: Amoun
Building 11/6/2009 0:00:00 $56.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -0488
APPLICANT /CONTACT PERSON HABER WILLIAM J JR & ANDREA L
ADDRESS /PHONE 395 PARK HILL RD FLORENCE (413) 585 -0682 O
PROPERTY LOCATION 395 PARK HILL RD
MAP 43 PARCEL 178 001 ZONE SR000) / /WSP 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 14 X 20 SHED W /12 X 20 ATT CARPORT
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 FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 of Building Official Date
'rote: 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.
City of Northampton lie
Building Department
212 Main Street � � o � �� � � � �� s "
Room 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
This section to be completed by office
1.1 Property Address ,
Map Unit
Overlay District
__ '. -. ElnrSt-BtstrfC CB Distric
SECTION '2 - PROPERTY' OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) V V L Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION I- ESTIMATED CONSTRUGTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building �j 'too � (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) Check Number
This Section Far Official se Onl
Date
Building Permit Number: Issued:
Signature:
Building CommissionerAnspector of 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: ._.._ R -- L :1— ' R.
Rear __. ' ( _..
Building Height
Bldg. Square Footage [7:71 %
Open Space Footage %
(Lot area minus bldg & paved.
P arkin g ) U
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book Pagel and /or Document # rn
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 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
.......
^' b: Ae t ere any proposed - anges o or a itlons o signs inten�lcedfor the 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) ❑ Roofing El
Or Doors 0
Accessory Bldg. Demolition ❑ New Signs [0] Decks [C] Siding [ED] Other [a
Brief Description of Proposed , ( ('
Work: 141 ( X 13 5 W1 CAC �o� roc" RFcto
Alteration of existing bedroom Yes X No Adding new bedroom Yes V No
Attached Narrative Renovating unfinished basement Yes X, No
Plans Attached Roll - Sheet
sa If New h "oiise.a>�rd ar adtiltlo�i`�to extsfit+�g'tiousii�c. +roi�plete�l�Fle,.fo�ouvirig:
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. Num ber 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 AU7t]ORIZAT]ON_- TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES iFOR. DUILDING 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
1, vV'� 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 u nder the pains and penalties of perjury.
Print Name
10-3
Signat er /Agent Date
s
ti
SECTION 8 - CONSTRUCTION SERVICES ,
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9.=Reaisteredi Home: #mprovertent.ontr�ctaz~ <. „ .. � r 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...... ❑
x ..
a '101
z
_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, of is ititeaded to be, a one or two family dwelling, attached or detached structures accessory to 91 m use, and/ or farm
structures. A person who constructs more than one home in a two -year period shall not be conside 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 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
N o amp on _ r tnanceg, e - ltrlam- dehusetts La =ws- Annotated.
Homeowner Signatur
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
��• www.mass.g ov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumb.ers
Applicant Information Please Print L b
Name ( Business /Organization/Individual): , c;
Address:
City /State/Zip: RoseiCe- r d(D�� Phone #: SSS - U�
Are you an employer?. Check the appropriate box: Type of project (required):
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 loyees These sub - contractors have. 8. ❑ Demolition
working for me in any capacity. employees and have workers'
9. Building addition
[No workers' comp. insurance comp..ins ' ❑
required.] 5. We are a corporation and its 10.0 Electrical repairs or additions
3 -am -a -homeowner �i&ing-aE-work - -- - - - cers ha v —L 1.
-❑-I?- lambing repairs or additions
myself; [No workers' comp. right of exemption per MGL 12,Q.Roof repairs
insuran required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance requited.).
*Any applicant -that checks box #d. must also fin out the section below showing their workers' compensation policy information
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
Tcontractors that check this box must.attached an additional sheet showing the naive of the sub -cony= tots and state whether or not those entities have
employees. if the sub - contractors have employees, they must.Mvvide their workers' comp..policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the polity and job site
formation.
Insurance Company Name:
Policy # or Self-ins. Lic. #: 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 ws required tinder Section 25A of MGL c. 152 can lead to the imposition of chmival penalties of a
fine up to $1 ".500.00 and/or one-year impriso as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against tfm - violator.. 1�e advised that a copy of this Statement may be forwarded to the Offii :P of
InvestiLyations of the DIA for insurance coveraze verificati
I do_hereby certify under the ' and penalties ofperjury that the information provided- above_fttrue�ru� correct___
Phone #:
LOther use only: Do irvt write m thu area, to 7e comp ted by city or town official
wn: Permit/License # _
thority (circle one):
Health 2. Building Department 3. City/Town Clerk 4. Electrical ector 5. Plumbin
- -.
_Ind
son: Phone #:
t
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
re The inspection nro that the building department be calle 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 inspectio 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 occupa
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 - issuers, 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,
,��� • 4 ( 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 2 � � j :
location ) 'j
�a sense D L a6 �-
�.
� �
'�
�..
A r A ��
\ � t V�
�,\ �`
,� /
,}
�" '
,�� �� �
�_
.�
F, �
t
��
'��
150'
t1
.�
� {�
�:
`,..�„)
�� � �'
tsk = ,
�""� g 4.J at"
}�
�,,.,�. . oma^ �?aasv.. nw... �.uM,.e.+e:..wauy.�...,.:.�»oea - .s.+vaw-,�sv+z+uw..e.�+*�+w�r.
�+�'
S ��
�� ��