44-090 (3) 964 FLORENCE RD BP- 2011 -0216
CIS #: COMMONWEALTH OF MASSACHUSETTS
MV.-Bloc 44 - 090 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Perrnit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate BUILDING PERMIT
Permit # BP-2011-0216
Project # JS- 2011- 000376
Est. Cost: $0.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 74487.60 Owner. BERGERON LEONARD & MARY ELLEN
Zoning: SR(100) Applicant: BERGERON LEONARD & MARY ELLEN
AT. 964 FLORENCE RD
Applicant Address: Phone: Insurance:
964 FLORENCE RD (413) 584 -8040 (�
FLORENCEMA01062 ISSUED ON :911312010 0:00:00
TO PERFORM THE FOLLOWING WORK.- INGROUND POOL (NOTE -
ELECTRICITY MUST BE DISCONNECTED PRIOR TO DEMO)
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 9/13/2010 0:00:00 $20.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
City of Northampton s
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413 - 587 -1240 Fax 413 - 587 -1272 R
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 4 SITE INFORMATION
1.1 Property Address
This section to be completed by office
q� y Ftcr' ncc 4CJ Map Lot Unit
Ho nice- � � d���O � Zone OvedayDistrict
E6 S i blst�lct , CB. District `
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
l.�nc�r�Q ti 1 �u �y X11 e� & 4 1 rd � / (0 -y
Name (Print) Current Mailing Address: /OrQ� 2.
Telephone /
Signature / 1 3
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
com leted by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee �¢
4. Mechanical (HVAC) ID6AA6 t NU'PSUP 0 `I' 10 , C) o
5. Fire Protection Poo L
6. Total= (1 +2+3+4+5) Check Number
This Section For Official Use Onl
Building Permit Number: Date Issued:
Signature: C)
Building Comm issioner/Inspector of Buildings Date
NOTE �W-IT 0 C,i r y AAA45T" ED Pry o rL.
lo
f
^
. ^ .
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 SiZC
Frontage
Side L:= R. L:L— R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bIdg & paved
# of Parking Spaces
(volume & Location)
A. Has a Special. Permit/Variance/ Finding ever been issued for/on the site?
NO «� �� / DDNTKNDVV YES v� ��
�
|F YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
»~�
NO «�� uvn/ m,vW ,cu
IF YES: enter 8cmk Page and/or Document#
«�� ��
B. Does the � �� site NO x~� DON7KNOYV YES
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs %obmobtained � Obt�ned �~� Date
�~� �~� ' '
��
C. Do any �gnsedston the property? �� vQ� � Y[5 «�� NO
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 �7»
|F YES, describe size, type and location:
E. Will the construction activity disturb (clearing, gradinexcav or filling) over 1 acre nrioit part ofo common plan
that will disturb over 1acre? YEGK � 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 Alterations) ❑ Roofing ❑
/ Or Doors ❑
Accessory Bldg. Ltd Demolition LJ New Signs [0] Decks [Q Siding [0] Other [0]
Brief Description of Proposedj� L
Work: ]LuL I tJ (N( ��U�1�1 0
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa. ,.lf leyt� =hot se aril, rr afi Tdt 'tin3to3'exi t�rrcihf oUtina�0 1 0 , 15 r f ita ii :
a. Use of buildin ne Family Two Family Other
b. Number of rooms in ea amity unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new constru Dimen
e. Number of stories?
f. Method of heating? Fir ces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck y Compliance form attached?
h. Type of construction
i. Is constructi 'thin 100 ft. of wetlands? Yes No. Is construction within 100 yr. odplain Yes No
j. Dep f basement or cellar floor below finished grade
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
0-1( as Owner /Authorized
Agent hereby declare that the statements dnd information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pain nd penalties of perjury.
Print Name
��, q i3 b
Signature of Owner/Ahent J Date IF
f
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9, RaisteretlFl ►lnitrave�neitttcinfactar. .. ..,:.. ..ww Not Applicable ❑
Company Name tration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c.'162, § 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 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 cons idered a ho meowner .
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 M
a P a
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
h '° wow mass goy1 a
- Workers' Compensation Insurance Affdavit: Builders/ Contractors /Electricia.ns/PIumb.ers
Applicant Information Please Print Legibly
Name ( Business /orgmizaiion/Individual):
Address: Of le-A(e_
City /Sta&e p: �) �� YIC �JV -k'' l (�Co hone .#:
Are you an employer?. Check the appropriate box: Type of project (required):.
1. ❑ I am a employer with 4.. E31 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 e�Ioyees These sub - contractors have. .8. Demolition
working for me m any capacity. Flo -3 es and hate workers'
[R\ workers comp. insurance Comp.
_ mcitr -anrP # 9 II�U7IdIII� aCldltlon
required ] 5. We are a corporation and its 10 • ❑ � repass or additions
3 g / V I am a homeowner doing all work officers have xercised their 11. ❑ Plumb mg repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required ] t c: 152, § 1(4)', and we have no
employees- [No workers' 13.0 Other
comp. insurance rcgtiir:&&j.
`Any applicant chat checks box #1 moist also fin out the section below.showmg their work='- cornpqatie®poiiay information:
t Homeowners _who submit this a$davit.iudicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
:Cont ctors th
raat check this box must attached an additional sheet showing the nanie of the sub-contract= and state whether or not those entities bave
employees. If the sub- contrwtrns have employees, dicy must provide tics workers' comp. .policy number.
I am an employer that u providing workers' compensation insurance for my employees Below is the policy �mnd job site
information
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 the p9hcy number. and expiration date).
Failure to secure coverage. as required under Section 25A ofMGL'c I 5 can Ie'ad* to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one.- year as well as civil penalties in the form of STOP WORK-ORDER and fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investikigi its of the DIA for insui a e coveraue `verifitftion
I do: hereby certify under the and penalties of perjury that the information provided�bavet�trur _cadcon — __
Si lure: ate• !3 1
CPhone
#:
Official use only. Do not write in this area, to be completed by ctty or town official
City or Town- Nrmitucense #
Issuing Authority (circle one): '
.1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #-
f,
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 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
�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
cft o understand the above.
(Home owner /resident's signatur requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date 1 1 1 0
Address of work ,,QQ
location �