44-79 (2) 22 AUTUMN DR BP- 2010 -1129
GIS #: COMMONWEALTH OF MASSACHUSETTS
e >44 =t?79 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 -1129
Protect # JS- 2010- 001656
Est. Cost: $4175.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(s4. ft.): 10018.80 Owner: ZERA JAMES A & LINDA R
Zoning: SR( 100 )//WSP II Applicant. ZERA JAMES A & LINDA R
AT. 22 AUTUMN DR
Applicant Address: Phone: Insurance:
22 AUTUMN DR (413) 584 -9342 (�
FLORENCEMA01062 ISSUED ON. 611112010 0.00.00
TO PERFORM THE FOLLOWING WORK.- REPLACE SLIDING DOOR & HATCHWAY&
WATERPROOFING
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 6/11/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -1129
APPLICANT /CONTACT PERSON ZERA JAMES A & LINDA R
ADDRESS /PHONE 22 AUTUMN DR FLORENCE (413) 584 -9342 Q
PROPERTY LOCATION 22 AUTUMN DR
MAP 44 PARCEL 079 001 ZONE SR(100) //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: REPLACE SLIDING DOOR & HATCHWAY& WATERPROOFING
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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF , 01kMATION 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
& t , � I 10
Signature of Buildin 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.
City of Northampton
Building Department `r
212 Main StreetT
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
D R Map` Lot - .: unit
1 2r /a c r j� -j /,, Zane Q erlay District
Ektt St Distric CIS District
SECTION 2 - _PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Tn► ha $ "r'wf -w Dom. r- L(ja#_e, , /7A
Name (Print) Current Mailing Address:
Telephone
Sign
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 Qpr �✓ �t o �, (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 For Official Use Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/inspectorof Buildings Date
d , "
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: 1 L• R - ? _
Rear --
Building Height
Bldg. Square Footage % I - 7
Open Space Footage %
(Lot area minus bldg & paved 3 ~
p arkin g)
# of Parking Spaces - - - --
Fill:I
volume & Location I
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 D KNOW Q 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 Q , Date Issued. } m
C. Do any signs exist on the property? YES 0 NO Q
s
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
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 ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [[- Other [�]
Brief Description of Proposed
Work: 12 6 or SiAs--r Dcw.i% .SThrs IJF4yilwc iG 8 L IfArc' — ^y
Alteration of existing bedroom Yes ' No Adding new bedroom Yes _p l - � No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa ft iiwif ti , l ad i ar if fir cr ., Ili # i+ ail �r :
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 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
I, 4' m9- s A Z?oSfzp 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.
J Ar a s A
Print Name
Sig re of Owner /Age Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9....Rstee lsfrirs �rtieiii8[ltoi' �� ` *�• : Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c.'152, § 25CM)
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...... ❑
, � t t
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 considered a hom eowner.
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 0,,, c 2,,\
j �
The Commonwealth of Massachusetts
Department of Industrial Accidents .
Office of Investigations
_ 600 Washington Street
Boston, M4 02111
' www.mass gov/dia
-Workers' Compensation Insurance Affidavit: Builders/ Contrac tors/Electricians/PIumbers
Applicant Information Please Print Legibly
Name (Business/organization/individual):
Address:
City /StateMp: Phone. #:
F 1. Are you an employer ?.Check the appropriate box: Type of project (required):. I am a employer with 4.. I am a general contractor and I
employees (fall and/or part time).
# have hired the sub- contractors 6. New co
2_ 0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling .
ship and leave no e�loyees These sub- contractors have S. ❑ Deniolition
wor for me in my �Pt3' employees_and1ave workers'
_comp. m�,7ranc 9. Q Bllrlding a&d1On
#' _
[N° workers' comp' in 10 Electrical airs or additions
required J 5. E] We are a corporation and its repairs
3.0 I am a homeowner doing all work officers havexercised their 11.0 PInmbing repairs or additions
right of exemption per MGL
myself [No workers comp. 12:Q.Roofrepairs
hisuranc a required.] t .c. 152 § 1(4), and we have no 13.❑ Other
employees. [No workers'
comp. insurance required.).
'Any applicant ihat ehecIm box #1 must also EU out the section below showing theirwotkers' compensation policy information
t Homeowner; who submit this affidavit.indicating they are doing an work and then hire outside contactors must submit a new affidavit indicating such.
IConuactors that check this box must_attached an additional shed showing the name of the sub- conttacton and state whedw ornot-those entities have
employ I th e su - contractor have employees, they must provide their wort=.' comp. policy numbs
f am an employer that is-providing 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 /Stafrizip:
Attach a copy of the workers' compensation policy declaration page the policy number and expiration date).
Failure to- secure coverage. as required `under Seetioa 25A of MGL c: 152 can lead to the imposition of crimm�l penalties of a
fine up to $1,500.00 and/or one -year imprisonment; as well as civil penalties in the form of a STOP'F ORDER. and a fine
of up to $250.04 a day against the violator. Be advised that a copy- of this statement maybe forwarded to the �Offi'ce pf ..+_
Investtsatioris of the DIA for insurance coverage verification. ...:: ..;:, :., .....- _
Yd " "hereby certify under the pains penalties of perjury that the informationrovidedlrbQV t`z _aad ever --
Si e: Date_
Official use only. M not write in this area, to be completed by city or town "official
City or Town: PermitUcense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical Inspector 5. PIumbina Inspector
6. Other F
Contact Person: Phone #:
4
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 roush 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
�ermits 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.
me owner /res' ent's signature requesting exemption)
I vATI call to schedule all required building inspections necessary for the building permit
issued tome.
Date ^/a
Address of work
location a �, A L4,J - (.cry tl DA I +
1= ' �dn.►sNco-r , IIA o ., o62