23A-029 SECTION 8 -- CONSTRUCTION SERVICES
8.1 Licensed Constructio rvisor: Not Applicable ❑
Name of License Holder : � `9 6
Lic�n Nufnb r
A. Ex o n to
<I3 / /
Si. natur: Telephone
!#,.:Re kirkie lrubi vemertf iiiitiattor , . ai Not Applicable ❑
�� (fir ) .3�
Comtlanv Name Registr t n umber
3 F
Address. Expir ion to
( vi J yy i�7 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 ❑
11.' 1.1V4
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 1083.5.1.
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 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ®— Roofing ❑
Or Doors Wi
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [D Siding [D] Other [D]
Brief Description of P / r
��(1�
Work: C
fAc11 -Y- - CD ) rilrll� / (e/k r� U
� �:mac? �. .`ca , L Alteration ofexisting bedroom Yes No Adding ne bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
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 la OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, k<*— /� 1 j��� _ It; , as Owner of the subject
property / p
hereby authorize / - (— � IVA
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, � � ( ( t.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.
F .. (
t 6 Signature of Ow - IAgen
y
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
i
Lot Size 1 i --�-- ----
Frontage H ! M_.
Setbacks Front r
Side L:' R: 1 L:1 . I R:= ._,1 i .
Rear 1 I
Building Height i°"
Bldg. Square Footage ---] % 1
Open Space Footage %
(Lot area minus bldg & paved �.a =1 `
parking) —
# of Parking Spaces - -----
Fill:
(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 DONT KNOW 0 YES 0
IF YES: enter Book ! Page ' and /or Document #1 _ ,
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: L
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO 0
IF YES, describe size, type and location: 1
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.
- .'air „ '4';',"-;-''1131‘.. 3
- City of Northampton �� i � � � ; ,
Building Department rlyOf-fFitt.Aif,V n , ,1"6:;:;,..14-
0 10 "' 212 Main Street
SUN 2 , \Room 100 r_E�`
�lorthartpton, MA 01060 �g
p 3-58 -1240 Fax 413- 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
'3 R k` . Map Lot Unit
Zone Overlay, District
Eim St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: _
Name (Print) Curr cling Address:
y Pc - yJ , Telephone
Signature
2.2 • 'zed • • ent: •
A li - 4... 4 s / ij l , �' " 46' n
Na • - - Current Addr Ss:
-- C
Signature /' Telephone
SECTION 3 -ES" MATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
36D6 . t")
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection . e�
6. Total = (1 + 2 + 3 + 4 + 5) ./l9l - CA..) Check Number}
This Section For Official Use Only
is t
Date
Building Permit Number: Issued:
Signature:
Building Commissionerllnspector of Buildings
: pate
,Y,Y.N = ' ") -p
57 PARK ST BP- 2010 -1184
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A - 029 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 -1184
Project # JS- 2010- 001720
Est. Cost: $3000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT C GOULD 090940
Lot Size(sq: ft.): 8319.96 Owner: KOSTEK PETER A & ELAINE A
Z_ TTP13(1 ROBERT C GOUL. D
AT: 57 PARK ST
Applicant Address: Phone: Insurance:
62 LYMAN ST (413) 531 -1391 0
GRANBYMA01033 ISSUED ON:6/23/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE SLIDER & LATTICE
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: OK. € (c i 10 L C 3
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
(-Akt..pc€1.1d ►� ' j irL1�i�KA .
Certificate of Oestiarrcy 6 a 14c C " i Signature:
FeeType: Date Paid: Amount:
Building 6/23/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
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 owri,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
jermits 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
7
. _
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investig,ations •
• ...-.7.-,._1=1...
600 Washington Street
- - - -7.1e— Z Boston, MA 02111
.--,..,,„
. ,
wwv.mass.gov/dia
, . -a ' -
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legiblv -'
- i c ,--- Th -
Name (Business/Organization/Individual): z l 42 ,,e+ 6 (-7,,A.,-x.,
.,,
Address:
.....--
-
- 41 Ad■ _ I - a - 4 i ' . IIPaa. il
City/State/Zip: , / 41.•- /1-41 Phone.#: AIL / 6-
Are you an employer? Check the ppropriate box: Type Of project (required): 11'
• 1. 0 I am a employer with 4.. 0 I am a general contractor and I
6. 0 New construction
p
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7• 0 Remodelin.g
2. a sole proprietor or partner-
These sub-contractors have
ship and have no -oloyees tt 8. 0 Demolition •
working for me in any capacity. employees and have workers •
9. 0 Building addidon
_ A. t .
[No workers' eomp. insurance ccunp.insm--ricr
10.0 Electrical repairs or additions 5. 0 We are a corporation and its
3. 0 I am a homeowner doing all work officers have Ccercisecl their . 11.0 Plumbing repairs or additions
lien Of exemption per MGL
myself. [No workers' comp. 120 Roof repairs . -
insurance required] t ' c. 152, § 1(4), and we have no
1_ j
employees. (No worlcers' 13. Other
eemP. =mance reclilired-i •
*Any applicant that checks box #1 must also fill out the section below showing their compensation policy infonnation. - -
t Homeowners who subrnit this aifidairit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. .
:Contract= that cheek 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 employee; they must provide their workers' comp policy number.
lam an employer that is providu4 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/Stafraip:' • - .
Attach a copy of the workers' compensation policy declaration page (showing the policy =tuber and expiration date).
Failure to secure cOverage . as required tinder Section 25A 'of MGL c. 152 can lead to the linpesitibri of Crinin41Peinidties of a
fine up to 51,500.00 and/or one-year impri.sonmenc as well as civil penalties in the form of a STOP WORK-ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
- Efitiations 6 ..- a : for int .., e coVernieierifieitiOn.
tiro 11_ ll It ,.. e p ,.' .an p , , .. s of perjury that the information provided4oveis_true_Und_Citrrect.___ _
• ( 111/ i' /
Si • ..e: < AnoriAl s ate- ,,, 0 . ___
II I' I •••• •'‘11
i AI i i -qui
Phone #: 4 .." / / - .
• - Official use only. Do not write in this area, to be complet.ed by city Or townOfficial.
• City or Town: • - Permit/License #
Issuing Authority (circle one):
'
- .
1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
•
•