44-067 993 FLORENCE RD BP -2012 -0197
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc 44 - 067 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0197
Project # JS- 2012 - 000303
Est. Cost: $1000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg. ft.): 10018.80 Owner: RHOADS SUSAN D & MARK D
Zoning: SR(100 )//WSP Il Applicant: RHOADS SUSAN D & MARK D
AT. 993 FLORENCE RD
Applicant Address: Phone: Insurance:
993 FLORENCE RD (413) 586 -5360 Q
NORTHAMPTON MA01 060 ISSUED ON :812612011 0:00:00
TO PERFORM THE FOLLOWING WORK. CONSTRUCT BASEMENT WALL
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 8/26/20110:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP- 2012 -0197
APPLICANT /CONTACT PERSON RHOADS SUSAN D & MARK D
ADDRESS/PHONE 993 FLORENCE RD NORTHAMPTON (413) 586 -5360 O
PROPERTY LOCATION 993 FLORENCE RD
MAP 44 PARCEL 067 001 ZONE SR(100)//WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT BASEMENT WALL
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 MMATION 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
0
Signature of 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.
e .ixseon a
Cit of Northampton rrn
? uil ing Department a
2 Main Street
oom 100 i1
. • amp'ton, MA 01060
-phone 4 Fax 413- 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 51TE INFORMATION
1.1 Property Address ��f ThisectFOn #o be completed by office r
I [�rstrc , 51 Distr /c `
SECTIO[V 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT n
2.1 Owner of Record
Name (Prin Current Mailing Address:
Telephone (O
Si ature
2.2 Authorized Aqent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION'S = ESTIMATED CONSTRUCTIbN COSTS
Item Estimated Cost (Dollars) to be
( ) � � Official Use Oniyi �
completed by ermit applicant ....... ��._... , • >. - „„ , ";
1. Building (a) Bmldin Per�mi# Fee
2. Electrical (b) Estimated Total Cas66
r.Oohs trut tion from:. 6
3. Plumbing r8:uildmg �4Permi #'Fee
,
4. Mechanical (HVAC)
5. Fire Protection , z
6. Total = (1 + 2 + 3 + 4 + 5) 19 7, , .'Gheck�filumber
This Section FarOffidgWse�0n1 -
Building P6hni Nuriiber ` � Date
Issuetl.
Sigrature _
s
Building Commissioner /inspector of Builiiings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed �Bu' LlujL y" g-
to be filled in by
artment .
Lot S ize �a
t
L
Frontage ;
Setbacks Front
Side L: = R: L: R: �
f
Rear
Building Height i 1
Bldg. Square Footage 01
U --
Open Space Footage p- % k x
(Lot area minus bldg & paved r I
-kin) �^
# 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 Register of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book Page4 and /or Document # €
B. Does the site contain a brook, body of water or wetlands? NO 0 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 0 NO 0
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 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
J
SECTION3- DESCRIPTION 60 PROPOSED WORK (check all applicable) ry
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [p] Other [O]
Brief Description of Proposed w CT1 (, ��(� j F' h1l f N
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
ouse�an �oraddit�on= to�existincthQ�s�ng;§comp ete' e�fotlow�ng.
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? riteplages or Woodstoves Number of each
g. Energy Conservation Compliance. Mat scheck,,Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Y-6s No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finishasd 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 70 BE COMPLETED�WHLN�
OWNERS AGEN7` C1R CONTRACTORAPI?LIES FOR BUItD1NG,PERMIT �� ��
I ' as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work autho ' ed by this buttding permit application.
Signature of Owner Date
I ' v � Owner
Agent hereby declare that the statements and information on the foregoing application are true and accurate to the s of muthonzed
y knowledge
and belief. ,
Signed under the pai nd penalties of perjury .
4
C C -mss
Print Name
Signature of wner gent Date
SECTION 8 CONSTRUCTION SERWI
CES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature f e'lepwne f .'
r ere otxrepro�tm+�n ` VoxitrCfa Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
.St =CTIQN 10- WORKERS' CONII'ENSATION INSURANCE AFFIQA1fITM, G Lrc ,152, § 25C(6)) l
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 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 j ob 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 unde this permit.
The undersigned "homeowner" certi s and assumes responsibili for compliance with t State Building Code, City of
j Northampton Ordinances, State an ocal Zoning s St f Massac se s G eral Laws Annotated.
r
Homeowner Signature
The Commonwealth of Massachusetts
Department of Industrial 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 Legibly
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. ❑ I am a general contractor and I
employees (full and/or part -rime). * have hired the sub - contractors 6. E] New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
- - These sub-contractors have ship and have no employees b tt e 8. E] Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. msurance.
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.JJ I am a homeowner doing all work officers have exercised their 11. E] Plumbing 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. ❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill 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.
$Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether 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 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/State /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 imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a 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
Investigations of the D for insurance coverage verification.
I do hereby certify
�114, er the pal a alt of p ry t at the information provided bove is 7tr, a and correct.
Si ature: 22 /�'} Date:
P � 5 3 � �./
- - - Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
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 #:
City of Northampton
Massachusetts�";�` § �
DEPARTMENT OF BUILDING INSPECTIONS ?�
212 Main Street • Municipal Building r �y
Northampton, MA 01060 r .
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 any 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 permits 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
r and inspections are made Th % I, 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.
Date
Address of work location