16A-020 .,
;5 i - FAMWAY VLG t` BP-2010-1131
GIS #: COMMONWEALTH OF MASSACHUSETTS
Imp:] loc :16A - 020 CITY OF NORTHAMPTON
Lot: -065 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category_ BUILDING PERMIT
Permit # BP- 2010 -1131
Project # JS- 2010- 001659
Est. Cost: $12000.00
Fee: $72.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin HOME MANAGEMENT SYSTEMS 46913
Lot Size(sq. ft.): Owner: HARRINGTON NANCY
Zoning: URA /WP/WSP Applicant. HOME MANAGEMENT SYSTEMS
AT. 501 FAIRWAY VLG
Applicant Address: Phone: Insurance:
107 PROSPECT ST (413) 525 -8888
EAST LONGMEADOWMA01028 ISSUED ON. 611612010 0 :00 :00
TO PERFORM THE FOLLOWING WORK.- REPLACE KITCHEN
CABINETS/COUNTERTOPS
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 6/16/2010 0:00:00 $72.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -1131
APPLICANT /CONTACT PERSON HOME MANAGEMENT SYSTEMS
ADDRESS/PHONE 107 PROSPECT ST EAST LONGMEADOW (413) 525 -8888
PROPERTY LOCATION 501 FAIRWAY VLG
MAP 16A PARCEL 020 065 ZONE URA/WP/WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid ;9-117 *IaPk
Typeof Construction: REPLACE KITCHEN CABINETS /COUNTERTOPS
New Construction
Non Structural interior renovations
Addition to Existin
Accessory Structure
Building Plans Included:
Owner/ Statement or License 46913
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
kzl� 6' 1 10
Signature of Building 6fficial 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.
as artm6rit use only
City of Northampton to iup 4 Permit
Building Department Curia C0t1DP reuvay Pe trtI'
212 Main Street Sevrier/5eptcgvaitauility
Room 100 �at� ' e� lvaila �
Northampton, MA 01060 Sets�ctf h �l§ IPI' An
phone 413 - 587.240 Fax 413 - 587 -1272 TSite Plan y,
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 Address l/� / �
1 F 1 � � � � �' t'f' Map � _ Lo � y Unit
L- �i .69 t 1 �7 Zon t
(� Q
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
t
N #%( C-Y 0 R t N G-TO N 50 ( '[� w v 1 a ,4
Name (Print) Current Mailing Addre s:_ O
Telephone
Si nature
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 (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) t'r 0, Check Number
This Section For Official Use Onl
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
i
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing ,4/ Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size ___...__ _......._ .
Frontage _.... ., - ... _... ...... .._ .._._._.. w,,.,._..
Setbacks Front m
Side L: :–._ R: ...,..,.. L: ?.. _.. _ ` R ::—,, .
Rear _..
Building Height
Bldg. Square Footage
Open Space Footage _ %
(Lot area minus bldg & paved
p arkin g)
# of Parking Spaces -
Fill:
volume & Location)_ ..... ... ... .... .. _._._ ._ ___ f._._ _._ . .._....._ . ,_._ __..,,_ _........,...,'
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW Q YES Q
IF YES, date issued:
-- --_- IF YES:__ Was t he_permit r e corded at the RegLqry-of - Deed - - NO Q DONT KNOW Q YES i
IF YES: enter Books Page- Document #
B. Does the site contain a brook, body of water or wetlands? NO 0, DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Cr
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 Q NO Q
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 ration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding [ [3] Other [Ifl)'
Brief Description of Proposed / L h C _ �J X /A� _ /J � — J
Work: J°�.J T /�.L %C,2.C��1 p.�` �t.G�.6z{ j
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a If New house and or addition to.existina housind comolete the following:
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
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.
Signatur of Ovo& Date
I 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.
Print Name
Signature of Owner /Agent Date
r
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor �-�^ Not Applicable ❑
Name of License Holder / _ W / ( - L ��Q y/ r f � C:5 ly q1 3
License Number
1 7 `� Ieo S !�� _i �' F �°� .COINa . 17* 0/0 t IA' /-2 C
Address Expifation Oate
fl
Signature Telephone
9. Registered Home Improvement.Contractor: Not Applicable / ❑
Company Name Reg istr Lion Number
Address Expiration Dat
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...... 1W
11. -- .Ho me,,Qwner Exemption`:
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 buildine 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
The Commonwealth of Massachusetts
Department of Industrial Accidents "
Office of Investig, ations
_ 600 Washington Street
Boston, MA 02111
:. sv www.mass govldia
-Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information L Please Print LegibIv
Name ( Business /Organiaation/Individual): Ml /V� 7 C-
Address: F175 c_% .S % , 6 of vNP_ f?64 e Io
City /State/Zip: Phone. #: 4/ —
Are you an employer? Check the appropriate bog: Type of project (required):
L ❑ I am a employer with 4.. Q I am a general contractor and I 6. Q New construction
full and/or part- time). * have hired the sub- contractors
employees (
listed on the attached sheet 7• (�2emodeling
2. K I am a sole proprietor or partner-
ship and. have. no, employees These sub - contractors have 8. Q Demolition
working for me in any capacity. employees and: have workers'
Q
.. 4. Budding addition
[No workers' comp: hisuran _ comp...msurance $ _
5. Q We are a corporation and its 10.1 Electrical repairs or additions
required ]
officers have xercised their 11. Plumbing repairs 3.0 I am a homeowner doing all work ❑ g ep or additions
myself [No workers' comp. right of exemption per MGL 12.[3 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.].
*Any applicant -that checks box #1 n= also M out the section below showing their workers' com pensatiion 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 ornotthwe entities have
employees. If the sub - contractors have employees, they must provide thcir workers' camp. policy number.
lam an employer that isproviding 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 /Statelzip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration
Failure to secure coverage. as required under Secti on'25A ofIvI M c. 152 can lead to the imposition o crimin4I 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 fire
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 DIA for insurance coverage verification
I to hereby* certify under the pains an p alties ofperjury that the information provided rs true and -__
Si lure: ate• — / O O /t7- .
Phone #:
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):
J. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
e
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 backrdl),
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 and inspections are
made
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