31A-039 ,--' Nlas,aclin■ctts - De:um of Public Salet■
Boarti of litiiklbaLt Retji ballots and Slanducth
License: CS 65242
, ...., ,
RestrIcted to; 00
LOUIS A TONELLI
35 FLETCHER AVE
BELCHERTOWN, MA 01007
c...77"....4.— ----........ Expiration: 8/10/2011
( "ouni., Tr: 3591
, -
4
, 072 , _ 6; / 1 I
-* -- -1- 1-- - ---- -- --- / 1 .1 ity. d /4
'Office o onsumer A airs me • usmess . egu ation
10 Park Plaza - Suite 5170 ,
.0 Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 156978
Type: Individual
Expiration: 8/21/2011 Tr# 287809
LOUIS TONELLI
LOUIS TONELLI
P.O. BOX 497
BELCHERTOWN, MA 01007
\r ' ' --- ----.- Update Address and return card. Mark reason for change.
Address 0 Renewal Eil Employment 0 Lost Card
,, 5-cm 0 50M-04/04-6101216
.. coltl/M0,11.14Wi4 g 0‘../1444adteldee4
Office of Consumer Affairs & usiness Regulation License or registration valid for individul use only .
' ---' HOME IMPROVEMENT CONTRACTOR
.---_-*- — /
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
'4=g = 11 . - - - 7 t Registration. 156978 10 Park Plaza - Suite 5170
t1 E 'ration' - 8/21/2011 Tr# 287809
- ----= - 7= - , 0 ,.;$. xPi
... Boston, MA 02116 -
Type: '- indflOtat
--
LOUIS TONELU 2 1_3 .
35 FLETCHER AVE:;-: , I, i 4 ..,
BELCHERTOWN,M4.910,07 Undersecretary Not valid without signaitual
- .
' A
.A .
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
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
l; 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
-,
The Commonwealth of Massachusetts
—, = Department of Industrial Accidents
ii, _ - el
t. rifl , ' Office of Investigations "
r =::
�
_ 600 Washington Street
_= ,? Boston, MA 02111
:. - www.mass.gov/dia .
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individnat): )l`J �i� i'1/1/1
Address: I,0Lc - -
City /State/Zip: Gtnk.S Mha C k7)Phone. #: (. 6 A
Are you an employer? Check the appropriate box: Type of project (required) : /
1.0 I am a employer with 4. 0 I am a general contractor and I 6. lc New construction
j employees (full and/or part-time).* have hired the sub- contractors
.2.11.1 I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship aatd have no loyees These sub - contractors have. . 8. 0 Demolition
working for me in any � employees and_have workers' - .
ytY 9: Building addition
mcnranrA - . .
[No workers' comp insurance
5. We are a corporation and its 10.0 Electrical repairs or additions
r
ems j • officers have xercised their .
3. I am a homeowner doing all work 11.0 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' 13.0 Other
comp. ins required. }.
`Any applicant that checks box #1= must .also fihl out the section below showing theirworkers' compensation policy information:
t Homeowners who submit this affcdavit: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 whetheror not those entities have
employees. lithe 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 /Stafe/Zip: -
Attach a copy of the workers' compensation policy declaration page - (showing the policy number and eaxiration date).
Failure to secure coverage: as required under .Sect on'25A'ofYIGL c: 152 can lead the niiposnt ion'of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment; as well as civil penalties in the form ofa STOP WORK ORDER and a fine
of up to $250:00 a day against the violator Be advised that a copy of thus statement may be forwarded to the Offi'ce of
I ri estieations of the DIA forinn — m inn coveraoe verifi iiii. .. ,
_ I do hereby certify under the pains and penalties of perjury that the information provided.nbove_rsirue and corre _
Signature: 4 Date; < <' 34;i% O . ,
Phone #: (ill) (d2'1 ° .
Official use only. Do not write in this area, to be completed by city or town offlciaL
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 #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : (Lj '�% 1�i�/(/) CO*1Al !/
License Number
Me • 4 P, id TGL , MAbc `b ' o 11
Ads c Expiration Date
Signatu eiephone
9 ;- . € � f _ § otn ( 'ntT: . ''�ror,N 7 %4G.:.RRIFINZEn NotApplicab � ❑
Company Name Registration Number
3� i.GTrJ re - tsM • 97\SA t 1
Address �,- ',A �1 Expiration Date
rZ %w't'�'rre7`r 1 ` �11S, Q 00 1 Telephone ( ) LT) - a
—
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GL. 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 ❑
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-vear 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 D Addition [] Replacement Windows Alteration(s) [A Roofing E i
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding [p] Other [CO
Brief Description of Proposed A , ( ;
Work: }�1 /�1� I
Alteration of existing bedroom Yes )( No Adding new bedroom X- Yes No
Attached Narrative Renovating unfinished basement Yes � No
Plans Attached Roll - Sheet
sa t N» ' ' irc r 611 r rei s c tint ifllTa 1alg .Yhr t find:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit .1 Number of Bathrooms ' �` (y
c. Is there a garage attached? 1-
i
d. Proposed Square footage of new construction. ^ ., Dimensions 20 ,( 40
e. Number of stories? ` 1
f. Method of heating? ��[,(% 9.4 l./
--- - Fireplaces or Woodstoves \ 14 - f Number of each , CtW
g. Energy Conservation Compliance. M sscheck Energy Compliance form attached?
h. Type of construction 1494'`7 t- 14 - Ri / QO ( l .,6M
i. Is construction within 10q -fC. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes le. No
i
j. Depth of basement or cellar floor below finished grade & /
k. Will building conform to the Building and Zoning regulations? V Yes No .
I. Septic Tank City Sewer V Private well City water Supply
SECTION 7a OWNER AUTHORIZATION - TO BE COMPLETED WHEN ,
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, A' X11. " P r' , as Owner of the subject
property 11
hereby authorize L O'U ' S 1 0 nci l i
to act on my behalf, 'n all m to
Signature of Owner Date
relativ to rk tthorized by this building permit applicati n.
/
I, L ol) I4. efave...iA • 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.
P •ame
ItPttc2
Signal rkar /Agent , Date
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 ! , F 1 1 . _
i
Frontage i i
Setbacks Front l ; ? i
Side L: R:i—_ L:€ 1 R:1 I
1
Rear s
I
Building Height f 1 = 1
i
Bldg. Square Footage = I 3 % 1
a i
Open Space Footage , % l
(Lot area minus bldg & paved l __ I
parking)
r
# of Parking Spaces •
Fill: . m . �.,_„ _ w.._., �.
(volume & Location) 1i
L
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:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO ir DONT KNOW 0 YES 0
IF YES: enter Book I 1 Pagel I . and /or Document # . _.
B. Does the site contain a brook, body of water or wetlands? NO >�4 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ,Date Issued: 3
C. Do any signs exist on the property? YES 0 NO 0 4
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 C`
IF YES, describe size, type and location: a
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 C.
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
,w
City of Northampton
Building Department
212 Main Street s 11451' �t t
Room 100 s
Northampton, MA 01060 ° r
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 NOV 3 0 2010
1.1 Property Address:
Tbis seotioft to be completed by office
41 6A.11 Map ' Lot '
Zona Overlay Dis trict
Eint.St District" CB District
SECTION 2 -PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
T� t �")
e 1C k l't ch, (.1(4- 4-R - r r< 7 m l�l�✓ �, lc.m
Name (Pri t) Current Mailing Ad ress:
tAi �� ` Telephone
Signature
2.2 Authorized Agent:
Na e 'nt) Current Mailing Address: ai
�.� (a13) Vi-i ' $1
Signatu \ Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by pemiit applicant
f �� (a) Building Permit Fee
1. Building 2
2. Electrical z,./9 (b) Construction Total of
from (6)
3. Plumbing �O Building Permit Fee
4. Mechanical (HVAC) �^
5. Fire Protection _ l v 4
6. Total = (1 + 2 + 3 + 4 + 5) 119 00 Check Number { 2,0 2
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Date
Building Commissionerllnspector of Buildings
p ECb S srnoKC°
File # BP- 2011 -0502 CO U(T6 CTO
APPLICANT /CONTACT PERSON LOUIS TONELLI p j,U H0 6 r O 1
ADDRESS/PHONE 35 FLETCHER AVE BELCHERTOWN (413) 323 -5074 fl
( LA-kiosc
PROPERTY LOCATION 197 ELM ST ((0 MAP 31A PARCEL 039 001 ZONE URB(100)/ , r � 2 ( 4 >
THIS SECTION FOR OFFICIAL USE ONLY: Cd N r(
PERMIT APPLICATION CHECKLIST l S
ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE Ra E RTC, 1, n (LCD
Fee Paid N I— ( '
Building Permit Filled out / t (Vk CC,
Fee Paid �?t� P
Typeof Construction:_FINISH ATTIC SPACE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 65242
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
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.
NE6bs sryt;oK6
File # BP- 2011 -0502
3J Go oCT6Crag
APPLICANT /CONTACT PERSON LOUIS TONELLI
wHoL NousE
ADDRESS/PHONE 35 FLETCHER AVE BELCHERTOWN (413) 323 -5074 ,
PROPERTY LOCATION 197 ELM ST b
MAP 31A PARCEL 039 001 ZONE URB(100)/ 1 L(t I '(?U Lou I 5
THIS SECTION FOR OFFICIAL USE ONLY: ¶O(„) Cd IU '
PERMIT APPLICATION CHECKLIST • L S
ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE PL�E� �'�� Cam" (213
Fee Paid Rt J
Building Permit Filled out �/ CC AJ ��
Fee Paid /07t09 A0 P�Tt p
Tvpeof Construction: FINISH ATTIC SPACE
New Construction
Non Structural interior renovations
Addition to Existin
Accessory Structure
Building Plans Included:
Owner/ Statement or License 65242
3 sets of Plans / Plot Plan
OL_ IXTI1SIG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
F LION 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
P • i .• elay
Signature of Build'mg 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.
• x . .I
i
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of '
Planning & Development for more information.
f BP-2011-0502
GIS #: COMMONWEALTH OF MASSACHUSETTS
. 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 PEI JVIIT
Permit # BP- 2011 -0502
Project # JS- 2010- 001104
Est. Cost: $36000.00
Fee: $216.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: LOUIS TONELLI 65242
Lot Size(sq. ft.): 16247.88 Owner: BLANCHARD FLETCHER A III & HEIDI A SCHILLER
Zoning: URB(100)/ Applicant: LOUIS TONELLI
AT: 197 ELM ST
Applicant Address: Phone: Insurance:
35 FLETCHER AVE (413) 323 -5074
BELCHERTOWNMA01007 ISSUED ON:12/20/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: FI NI SH ATTIC SPACE
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 12/20/2010 0:00:00 $216.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
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Planning - Decision City of Northampton
Hearing No.: PLN -2010 -0005 Date: September 9, 2009 •
APPLICATION TYPE: SUBMISSION DATE: I I II 1111 II I 11111111
Elm Street Historic District Permit 7/27/2009
2009 000 5 9
Applicant's Name: Owner's Name: Bk: 9993Pg: 153 Page: 1 of 2
NAME: NAME: Recorded: 10/15/2009 01:08 PM
BLANCHARD FLETCHER A 111 & HEIDI A SC BLANCHARD FLETCHER A Ill & HEIDI A SCHI' —IL ')
ADDRESS: ADDRESS:
197 ELM ST 197 ELM ST
TOWN: STATE: ZIP CODE: TOWN: STATE: ZIP CODE:
NORTHAMPTON MA 01060 NORTHAMPTON -MA .01060
PHONE NO.: FAX NO.: PHONE NO.: FAX NO.:
EMAIL ADDRESS: EMAIL ADDRESS:
Site Information: Surveyor's Name:
STREET NO.: SITE ZONING: .. .COMPANY NAME:
197 ELM ST URB(100)/
TOWN: ACTION TAKEN: ADDRESS:
NORTHAMPTON MA 01060
MAP: ' BLOCK: LOT: MAP DATE: • SECTION OFBYLAW: " """ °i � ° `' •
31A 039 001 TOWN: STATE: ZIP CODE:
Book: Page:
5037 , 176 PHONE NO.: FAX NO.:
EMAIL ADDRESS:
NATURE OF PROPOSED WORK:
Replace front door & sidelights
HARDSHIP:
CONDITION OF APPROVAL: isECEIIVE1
1) Approved the application for a new front door and sidelights, with thre itions:
1.No highlights on the door and use a six panel wood door; and , 9 �� 2.Door and windows fit within the footprint of the existing door and wi f ✓
3. The windows have permanently mounted integral mullions
FINDINGS:
CITY CLERKS OFFICE
COULD NOT DEROGATE BECAUSE: - - NORTHAMPTON, MA 01061)
FILING DEADLINE: MAILING DATE: HEARING CONTINUED DATE:. : ` DECISION DRAFT BY: APPEAL DATE:
7/18/2009 8/25/2009 9/15/2009
REFERRALS IN DATE: HEARING DEADLINE DATE: HEARING CLOSE DATE: FINAL SIGNING BY: APPEAL DEADLINE:
8/18/2009 9/10/2009 9/1/2009 10/1/2009 9/29/2009
FIRST ADVERTISING DATE: HEARING DATE: . VOTING DATE: DECISION DATE:
ss
8/18/2009 9/1/2009 9/1/2009 9/9/2009
SECOND ADVERTISING DATE: HEARING TIME: VOTING DEADLINE: DECISION DEADLINE:
8/18/2009 5:35 PM 10/1/2009 . _ .9/25/2009
MEMBERS PRESENT: VOTE:
Martha Lyon votes to Grant
Edythe Ambroz votes to Grant
Bruce Kriviskey votes to Grant
Pauline Fogel votes to Grant •
MOTION MADE BY: SECONDED BY: 'VOTE COUNT: • . • . DECISION:
Bruce Kriviskey • Martha Lyon • 4 , Approved with Conditions • •
MINUTES OF MEETING:
Minutes are available at OPD. Appeals must be filed with the Pioneer Valley Planning Commission within 20 days of the recording of this
permit with the City Clerk.
GeoTMS® 2009 Des Lauriers Municipal Solutions, Inc.
•
•
File # MP- 2010 -0005
APPLICANT /CONTACT PERSON Schiller, Heidi A. & Blanchard, Fletcher A. II
ADDRESS/PHONE 197 Elm Street
PROPERTY LOCATION 197 ELM ST
MAP 31A PARCEL 039 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT nes `
Fee Paid J ✓
Building Permit Filled out
Fee Paid
Tvpeof Construction: REPLACE FRONT DOOR
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 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 r Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed 1/
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
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 the Office of
Planning & Development for more information.
Information and Ins•
tructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract, of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of suds employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a buisiness or to construct heildings hi the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage-required."
Additionally, MGL chapter 152, §25C(7) states `Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until aooeptablc evidence of compliance with the insurance
requirements of this chapter have been presentedtto the contracting authority."
Applicants •
•
.Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sab-contractoz(s) name(s), address(es) and Phone numba(s) along with their catificate(s) of
insurance. Limited Liability Companies (LIB or Limited Liability Partnerships (L12) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. Ilan LLC or LLP does have
employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
.. Acxideats for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law orif you are required to obtain aworkusrs'
• compensation policy, please call the DePartment at the number listed below. Self - insured companies should enter their
self- imvrance license number on the appropriate line.
City or Town Officials •
Please be sure that the affidavit is complete and printed legibly. The Deparment has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Inver has to contact you regarding the applicant.
Please be sate to fill in the permidlicense number which will be used as areferrax number. In addition, an applicant
that must submit azdtiple petmidiicense applications in any given year, need only submit one affidavit indicating current
policy iafoauati nn (if necessary) and under "Job Site Address" the applicant should write "all-locations in „(city or
- town)" A copy of tihe affidavit that has been officially stamped or marked by the dty or town maybe provided to the
applicant as proof tats valid off. jdavitis on file for figure penults or licenses. -knewaffdavit must be 5ILedou teach
J4_ obfahwgaaioeaae. ocpemtitnot molslodiosoybasin *oeici •
.(ix* a °P8.# °'ip POPP kart. ea ,} PM= i - ioTa wl 40s P3avh f
• •T7he'Ofoe OfInirestigations would him to thank you in advance far yarir 000paabiaa and ahonldyoiu bays any questions;
please do sot { a to give YS a till. ,.� Y.roviu!Nt . .••• ,:.' . i y{ ; r . . ..
. The Department's address, � thoM fax timber: ..
The Commonwealth of Massachusetts •
Deputment of In4t*lal A+ idettts
•
't1 i'ii of in esti itlana
604 Washingicai Street
• .. oston,:MA021I1
T e l . # 617 - 727 -49O ext 406.91 1-877- MAS$$AFB •
Revised 11 -22.06 Fax # 6114274749 • • • •
www.naassgov/d1a • •
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
is r c = �lit� Office of Investigations
_ y 600 Washington Street
Boston, MA 02111
� �• --- va wwH.mass.gov /din
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-time).* have hired the sub -contractors 6. ❑ New construction
2.0 I am a sole proprietor or partner- listed on the'attached sheet. 7. ❑ Remodeling
ship and have no employees Thy sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t reqiiired.] 5. ❑ We are a corporal ion.and its 10.0 Electrical repairs or additions
3. crI am a homeowner doing all work officers have exercised their _ 11.0 Plumbing repairs or additions
•
•
myself. [No workers' comp. right Of exemption per MGL 12.0 Roof repairs
insurance rec ] t c.152, §1(4), and we have no 13.❑ Other employees. [No workers' .
. . comp. insurance required.]
*Any applicant that cheeks box /1 must-also fill out the section below showing their wotlaehs' compensation policy information.
t Homeowners rho submit this affidavit indicating they are doing all work and then line outside contactors must submit a new affidavit indicating such. •
:Contractors that check this box must attached an additional sheet showing the more of the sub 000hada s and state whether or not those entities have
employees. Mk subcontractors have employees, they must provide their Veneers' comp. poky 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. Lit:. #: Expiration Date:
• . Job Site Address: . • City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(shotving the policy number and expiration date).
Fafiure.ti secure coverage as required order Section 25A of MOL c. 152 am lead to the imposition of terminal penaites of a
fore tlp to S1,500.00 and/or =year inipritormient, as well as civil pt ntifiec inure form ea STOP WORK ORDER and a fine .
• of up to $250.00 a day against the violator. Be tlidviaed that a copyof this staterrienrmay be forwarded to the Office of
r Irnyenti t!ations ofth IMA for h arms c overag verification. . •
/do hereby ' - the pales , -, , tkatthe b orasatlon piovkied Is and correct
phon ti: . S K5 -
e . - i-
Official use only. Do not write to this area, tb be contpleteaby c!(v or town official
City or Town: Pez m t/Lcense I
Issuing Authority (circle one):
. 1. B oard of Health 2. Building Department 3. City/Town Aerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: • Phone #:
.
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 couStruetiOn 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 backfili)
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
/I i c � � (' J\ ( / c � 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 /67/0
Address of work location ( ( l (31 Ci
Y a +Zs1
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
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.- Home Owner 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 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 nd Local Zo 'ng La s and,Stat f Massachusetts General Laws Annotated.
Homeowner Signature i ,e / !(,i, L
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement 1p/indows Alteration(s) Roofing n
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [El Siding [O] Other [El]
Brief Description of Proposed 7 (
Work: re. {Act ce --((en 'fi 'C1 e i 1 ( r
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 existing housing, complete the following:
a. Use of building : One Family 1 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.
Signature of Owner Date
, 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 l
( ??4z(a
, Signature of wner /Agent Date
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: L: R:
Rear
Building Height
Bldg. Square Footage cyo
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 2 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q 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 Q NO
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
' Department use only
. City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
C) 2 Room 100 Water/Well Availability
��� Northa mpton, MA 01060 Two Sets of Structural Plans
phone 413 -587-1240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify
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
1 7 C I } _ Map Lot Unit
()‘et k(7`. -- ,
l_ ' iao Zone Overlay District
1 ` Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
F1(2, k k p R
-(_u_L ._i- tei 7 0-, ,,, .,„
Name (Print) ( Current Mailing Address: 0 ?0 C(%
' 7(C ( C ? _ ,,c, „,, '.1--,:-" Telephone
Signature {Y LC ( ( i‘__((
�
2.2 Authorized Agent: JJJ
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit 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) Check Number /(O7 ?- `
This Section For Official Use Only
Permit Number: Date
Building Issued:
Signature: .
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0134
APPLICANT /CONTACT PERSON SCHILLER HEIDI & FLETCHER BLANCHARD III
ADDRESS/PHONE 197 Elm Street NORTHAMPTON (413) 585 -5187 0
PROPERTY LOCATION 197 ELM ST
MAP 31A PARCEL 039 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out T"
Fee Paid 1 6 V ( `� —
Typeof Construction: REPLACE FRON'tDOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan D ®U- M-'AST /+n R QG "6 me WiTs O f- 15Ta R ' t C
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON t 5T Qt CT F E irL lA 4 r
IN PRESENTED:
pproved 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
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.
•
197 ELM ST BP- 2011 -0134
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 039 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit # BP- 2011 -0134
Project # JS- 2006 - 000730
Est. Cost: $3000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 16247.88 Owner: SCHILLER HEIDI & FLETCHER BLANCHARD III
Zoning: URB(100)/ Applicant: SCHILLER HEIDI & FLETCHER BLANCHARD 111
AT: 197 ELM ST
Applicant Address: Phone: Insurance:
197 Elm Street (413) 585 -5187 ()
NORTHAMPTONMAO1060 ISSUED ON:8/30/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE FRONT DOOR - MUST MEET
HISTORIC DISTRICT REQUIREMENTS
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 8/30/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
BLDG. � DPW CITY CLERK
Planning - Decision City of Northampton
Hearing No.: PLN- 2010 -0005 Date: September 9, 2009 •
APPLICATION TYPE: SUBMISSION DATE:
Elm Street Historic District Permit 7/27/2009
C ,l
Applicant's Name: Owner's Name:
NAME: NAME:
BLANCHARD FLETCHER A 111 & HEIDI A SC BLANCHARD FLETCHER A 111 & HEIDI A SCH!
ADDRESS: ADDRESS:
197 ELM ST 197 ELM ST
TOWN: STATE: ZIP CODE: TOWN: STATE. ZIP CODE.
NORTHAMPTON MA 01060 NORTHAMPTON MA 01060
PHONE NO.: FAX NO. _ PHONE NO.: FAX NO.:
EMAIL ADDRESS: EMAIL ADDRESS:
Site Information: Surveyor's Name:
3 =- SITE ZONING: COMPANY NAME:
. : E Lfit ',. -, URB(100)/
TOWN: ACTION TAKEN:. ADDRESS:
NORTHAMPTON MA 01060
• LOT: MAP DATE: SECTION OF BYLAW:
* Y
TOWN: STATE: ZIP CODE:
Book: Page:
5037 , 176 PHONE NO.: FAX NO.:
EMAIL ADDRESS:
NATURE OF PROPOSED WORK: - -
Replace front door & sidelights
HARDSHIP:
CONDITION OF APPROVAL:
1) Approved the application for a new front door and sidelights, with three conditions:
1.No highlights on the door and use a six panel wood door; and
2.Door and windows fit within the footprint of the existing door and windows; and
3.The windows have permanently mounted integral mullions
FINDINGS:
COULD NOT DEROGATE BECAUSE:
FILING DEADLINE: MAILING DATE: HEARING CONTINUED DATE: DECISION DRAFT BY: APPEAL DATE:
7/18/2009 8/25/2009 9/15/2009
REFERRALS IN DATE: HEARING DEADLINE DATE: HEARING CLOSE DATE: FINAL SIGNING BY: APPEAL DEADLINE:
8/18/2009 9/10/2009 9/1/2009 10/1/2009 9/29/2009
FIRST ADVERTISING DATE: HEARING DATE: VOTING DATE: DECISION DATE:
8/18/2009 9/1/2009 9/1/2009 9/9/2009
SECOND ADVERTISING DATE: HEARING TIME: VOTING DEADLINE: DECISION DEADLINE:
8/18/2009 5:35 PM 10/1/2009 9/25/2009
MEMBERS PRESENT: VOTE:
Martha Lyon votes to Grant -
Edythe Ambroz votes to Grant
Bruce Kriviskey votes to Grant
Pauline Fogel votes to Grant
'MOTION MADE BY: SECONDED BY: VOTE COUNT: DECISION:
Bruce Kriviskey Martha Lyon 4 Approved with Conditions
MINUTES OF MEETING:
Minutes are available at OPD. Appeals must be filed with the Pioneer Valley Planning Commission within 20 days of the recording of this
permit with the City Clerk. /'-
GeoTMS®2009 Des Lauriers Municipal Solutions, Inc.
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 processiequires 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-conj unction- to_the_buildi ..per itissued,-- 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Vii. . Office of Investigations •
• w J l 5
=EE 600 Washington Street
"' a Boston, M4 02111
www.massgov /dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): e liZ -{tOO 44. C 'S ci r J 1 I4(,
Address: 0. SeX 1 / 2 ✓� '1 �UiF� Me . ,
City /State/Zip: ��D4 lam. CiallPhone. #: (4t C-- 57-(D
Are you an employer? Check the appropriate box: Type of project (required): /
1.0 I am a employer with 4. 0 I am a general contractor and I
,__/ employees (full and/or part time).* have hired the sub - contractors 6. ❑New construction
' 2.14 (J I am a sole proprietor or partner- lid on the attached sheet. 7. LRemodeling
ship and have no employees These sub - contractors have. 8. 0 Demoli
working for me in any capacity. employees and have workers'
Y P tY- $ 9. 0 Building addition
No workers' comp. insurance _ comp. _insurance.
_.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am -a homeowner-doing-all-work __o ve xercised ice- _ LLD-Plumbing ng repairs or additions
myself [No workers' comp. right of exemption per MGL 12. Roof repairs
insurance re t c. 152, §1(4), and we have no 0
required.] Other
employees. [No workers'
comp. insurance required.]
*My 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. .
Iam 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 51, 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 5250.00 a day against the violator. li e advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c =fy under the pains and penalties of perjury that the information provided _abnve_i _truenndicorrecL
Signature �'1 Date, "1,14 0
Phone #: ��JJ Cri/ •
Official use on ly. D not write in thi area to be edinpleted by city or town afficiaL
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 i^
Contact Person: Phone #: -
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
KN t.
Name of License Holder : 1 �� 7 l c,
License Number
' c Y MA O 11
ress Oko.n Expiration Date
Telephone
9. Registered .HomelmorovementCorifraetor 14-k i _ ...t ..t : Irv Not Applicable ❑
L (6)4A Caglg'C 7vE) 5 )‘e. S L1.C-f
Company Name Registration Number
R c)k Aqe. , 'Ca1.1J, N &(2t 1 l
Address a� Expiration
Telephone (41 621 314C3
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 ❑
The_current_exemption for "homeowners" was extended to include Owner 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'' c ertifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ur ind' ance5; Sfa e n 1" • i .o . -' .: -• .-
s Laws- Annotated.
Homeowner Signature
1
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement mdows Alteration(s) l� Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other [0]
Brief Work Description of Proposed O ^ , CX , `a k.6,.. / Og OW I-
I Alteration of existing bedroom Yes No Adding new bedroom Yes j No 1 L��
Attached Narrative Renovating unfinished basement Yes / No
Plans Attached Roll - Sheet
6aii tiiN kiiifs andL r adds o t ei i ngho sins amp `ete the 'fa lawir q:
a. Use of building : One Family 1 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 o R CONTRACTOR APPLIES FOR BUILDING PERMIT
1, re cil r ((3. , as Owner of the subject
property // // /"`�� hereby authoze ' / c
to a on y behalf, in all matt s re work authorized by this building pe it application.
Sign a of Owner Date
1 k7L - [ '
t . U..C�
- , as Owner /Authorized
Agent hereby declare that the statemen 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.
& TGA
Print Name
Signature of Owner /Agent
\ 1 Date
w
I
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 . . _ _ _.,. .
i
s _ f ..
Frontage . _.._.
Setbacks Front ) I g r
Side L R L:. R:'., _ °
r ___ 1 t -,
Rear
Building Height W "'
Bldg. Square Footage I a l j ? % 1 I f" '
Open Space Footage % _-
(Lot area minus bldg & paved _�_ 1
parking)
# of Parking Spaces -,------ • - -• - -° --
Fill: i
(volume & Location) L -- l , --. .
A. Has a Special Permit /Variance /Findin ever been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:; I
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book a Page i and /or Document if
B. Does the site contain a brook, body of water or wetlands? NO (25 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
, Date Issued:
C. Do any signs exist on the preperty? YES Q NO id
IF YES, describe size, type and location:
- "
D : `Are ttfiere any proposed c ranges o or a rtlons ofdins intenhe'd for the property ? YES Q NO d
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, ex avation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
.
City of Northampton �.Y
r . Building Department 3� N
212 Main Street € _
rtoom`100 m ,
Ati
Northampton, MA 01060 i €
phone 413 - 587 -1240 Fax 413 -587 -1272
773, 2tif ixtrAl l
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: ` ^ �,
t J/ 7
�'^� ` G Z C- Map Lot Unit
Zone Overlay District
ElrmSt °`District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record '
Name (Print) • Current M i' / n Addr s: fY
t( s c f ( t Telephone ` s � 0
Signature
2.2 Authorized Agent: 1 -
LOOts 'P O. sc Aroci .G' irt,JJ t.�lo
r
N. - Print) Current Mail 1
Mailing Address: ChOCT
(4 (,7; — 1.-rr>0
Signat - Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed b/permit applicant
1. Building /l, (a) Building Permit Fee
2. Electrical ,,rr7� (b) Estimated Total Cost of
�r/0• Construction from (6)
3. Plumbing l . O � Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection ut"-{t<
6. Total = (1 + 2 + 3 + 4 + 5) ,, 0D , Q Check Number d ` J`5-
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
•
File # BP- 2010 -0748
APPLICANT /CONTACT PERSON LOUIS TONELLI
ADDRESS/PHONE 35 FLETCHER AVE BELCHERTOWN (413) 323 -5074
PROPERTY LOCATION 197 ELM ST
MAP 31A PARCEL 039 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out r%
Fee Paid
Typeof Construction: DEMO & REFRAME ATTIC SPACE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 65242
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
tila 3/ I 0
Sign re of Building icial 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.
1 Sr BP- 2010 -0748
GIS #: COMMONWEALTH OF MASSACHUSETTS
, p :I31ock: 31A - 039 § 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 -0748
Project # JS-2010-001104
Est. Cost: $6000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: LOUIS TONELLI 65242
Lot Size(sq. ft.): 16247.88 Owner: BLANCHARD FLETCHER A III & HEIDI A SCHILLER
Zoning: URB(100)/ Applicant: LOUIS TONELLI
AT: 197 ELM ST
Applicant Address: Phone: Insurance:
35 FLETCHER AVE (413) 323 -5074
BELCHERTOW NMA01007 ISSUED ON:2/23/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: DEMO & REFRAME ATTIC SPACE
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 2/23/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
, , ( r ,T
I,,, lI i., _ . l ,
11" `
File No tff:c. - P'''' ,. . I LICA 'ION 1O 2
Q Please_ .- 0 - 6 - pup 3' ildin
' 7 ' 9 -, . `rin all information and return th form to the B u g
t .
i Tnc -(? with; the $15 filing fee (check or money order) payable to the
City of Northampton Il &r\c',Narr
1. Name of Applicant: �1 \ �t fe '�' I e I k -
Address: 11 El � S�._ ; M r , Telephone: `T Y5 51 7
2. Owner of Property: e as aYbL)Q.
Address: / Telephone:
3. Status of Applicant: Owner `� Contract Purchaser Lessee Other (explain)
4. Job Location: t 1 60-) `mil' _
x.Y ,,i mac. - >};,� �-� x�'�' �- +. te s roi `',` ;"41'1 a y, 1 ,;
',,` 'Fame ' '' O -'W': lt map; :' '3- of 5" =ar . 77: ". a" � . '$tf'i � `S .
t � ` .t e �i '.' �" �, �a rz >zs � � " w�.,.'W . � � x- }M -,, 'S� fit r ."
.� ; , . g gf in W4kP �� n entr asuness.. isti ict
t f l t4' '�*�,`??z° ?i- : *5-- i7, - , 4,-, ,':, 41 �J / L ' 'ICI a*. "G .,. ,n .w a z ,vF s' -
5. Existing Use of Structure /Property:S
6. Description of Proposed Use /Work /Project /Occupation: (Use additional sheets if necessary):
Sty .1 �S k. \0
•
7. Attached Plans: Sketch Plan Site Plan Engineered /Surveyed Plans
8. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO ` DON'T KNOW YES IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
I ti
NO 1/ DON'T KNOW YES � � � I
IF YES: enter Book Page an
9.Does the site contain a brook, body of water or wetlands? NO (1/4..----- DONT M Q�Q O,
til C3 --
IF YES, has a permit been or need to be obtained from the Conservation Com
Needs to be obtained Obtained +,
, a
W ADocuments\FORMS \original \Building- Inspector\Zoning- Permit- Application- passive.doc
File # MP- 2010 -0005
APPLICANT /CONTACT PERSON Schiller, Heidi A. & Blanchard, Fletcher A. II
ADDRESS/PHONE 197 Elm Street
V ',z : ":fie m .' " '
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 FRONT DOOR
New Construction
Non Structural interior renovations
Addition to Existing ) /S- * 1114
Accessory Structure
Building Plans Included:
Owner/ Statement ui Lieeise
3 sets of Plans / Plot Plan
THE FOLLOWING ACTI N HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRES TED:
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
P t from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commis • n Pemiit DPW Storm Water Management
2. de
Signal e 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 the Office of
Planning & Development for more information.