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SPECIAL SERVICES CUSTOMER INVOICE - Continued Last Name: DAWSON Page 3 of 4 NO. 8452 -47339
HOME DEPOT DELIVERY #1
(Continued) REF #V29
END OF HOME DEPOT DELIVERY - REF #V29
TOTAL CHARGES OF ALL MERCHANDISE & SERVICES
ORDER TOTAL $4,671.54
SALES TAX $0.00
TOTAL $4,671.54
ALANCE DUE $4,671.54
END OF ORDER No 8452 -47339
n• ....a...___ _ r+..... ,
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'4 No. 8452-47339 --
ALI DAT! ON AREA
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i // t' I *** CONTINUED ON NEXT PAGE ***
_
1111 111 El
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(9801) 0100056420
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_ __... i.
C"36(1,m;u1Artrdee:rmder
City of Northampton
S
p a y '
Massachusetts �w <
*
DEPARTMENT OF BUILDING INSPECTIONS'
212 Main Street • Municipal Building �r Ctr
Northampton, MA 01060 .1"P
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
and inspection are made
C �t ? ° 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.
ll
Date [� - E-' eit
Address of work location F 17 81 Or- I 1:r £ . +
J
9. ALL INFORMATION MUST BE COMPLETED: PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION.
This column to be filled in by
the Building Department.
Existing Proposed Required by
Zoning
Lot Size
Frontage N/A N/A N/A
Front:
Setbacks:
Side: 6.f+ L: R: J + L: R:
Rear: fj
Height I g
% Open Space: 1
(Lot area minus bldg andn
�
Paved parking) �/
10. Certification: I hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: l J ! APPLICANT'S SIGNATURE �"4" v V_
NOTE: Issuance of a permit does not relieve an applicant's burden to comply with all zoning requirements
and obtain all required permits from the Conservation Commission, Department of Public Works and other
applicable permit granting authorities.
,�<H�MPro City of Northampton
" rjRf` ; Massachusetts
lY ^ T
2042 � W
{ t D R T OF BUILDING INSPECTIONS
111t • Building
21 Main Street Municipal Bu ld g s
- PECTii ' Northampton, MA 01060 3 � W
DEi T 0 'r BUts 01 �
INSPECTOR N0
ACCESSORY STRUCTURE PERMIT APPLICATION
(For freestanding structures less than 200 sq. ft., at least 5 feet from any other structure)
Permit Fee: $25.00 Check # 5-06
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: I
(I l tom , f1.
Address: 7'7 '7 6C64 v r.+.%4,.. r �`�G,C= � f'r t (c ( Telephone: z iC j �/, -° . lr3 )'
2. Owner of Property: (j -( 0 ^ � I -v� ), t (It }44 1 x -r✓ f
/ ,+�
Address: e r, erefse t c��b W'.• � t t'r,rti,C -r. ,I'2''. Z te.7 Telephone: L i 3 - 5 - 7 4 4 - 1T3 r
3. Status of Applicant: Owner Contractor
4. Structure Location: -7 7 or‘: tie, l 0
Parcel ID: Zoning Map # Parcel #_ District(s)
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Use of Property: Single or Two Family: IA Multifamily: Commercial:
6. Description of Proposed Structure:
One Story Shed under 200 sq. ft.: X Freestanding Deck under 200 sq. ft., less than 30" above grade:
Other (describe): x 7 r te+
7. Attached Plans: Sketch Plan ) . Site Plan Plot Plan
8. Does the site contain a brook, body of water or wetlands? NO X DON'T KNOW YES
IF YES: Has a permit been, or need to be, obtained from the Conservation Commission?
Needs to be obtained Obtained , Date issued
CONTINUED ON NEXT PAGE
tAOLO 4-0 t\- LS OK
File # MP -2013 -0019
E/)) OtERX
APPLICANT /CONTACT PERSON DAWSON CARL E & TINA M BtklLD 06. rERIIM
ADDRESS /PHONE 77 BROOKWOOD DR (413) 586 -7535 0
PROPERTY LOCATION 77 BROOKWOOD DR "JOT 7_01,./(9 {) tX
MAP 29 PARCEL 392 001 ZONE
CMG 81(4 7 /
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid �i
Building Permit Filled out .ff t� p�
Fee Paid
Typeof Construction: ZPA - 14 X 24 SHED
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
INFO ATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER : §
Intenuediate 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
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.
City of Northampton
Massachusetts w �f
( x AA
DEPARTMENT OF BUILDING INSPECTIONS � S %
r - %. J
212 Main Street • Building � ,t
Northampton, MA 01060
sON
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
and inspections are made
0 4,-( � 1�� understand the above.
(Home ow er /residents signature requesting exemption)
( ' 9 q 9 p )
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date �--
Address of work location l '? Arookcc, c o‘A O i
� rt � C � 711/4-
y The Commonwealth of Massachusetts
--"-'--- Department of Industrial Accidents
Office of Investigations
s 600 Washington Street
* , I � , ` Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information ( / Please Print Legibly
6 Name (Business /Organization/Individual): n `
Address: k c,�zz,� / Dl�� �C°-
City /State /Zip: F (Gr e/r/c 4 v l& 6 )- .Phone #: c f / 3 - a2 5 3 S
Are you an employer? Check the appropriate box: Type of project (required):
I. {_� !n I am a vui vi i� ., emp w ith 4. n I am a general contractor and I r , ,
employees (full and/or part- time).* have hired the sub - contractors ° U i3 construction
listed on the attached sheet. 7. n Remodeling
2.❑ I am a sole proprietor or partner -
ship and have no employees These sub - contractors have 8. ii Demolition
working for me in any capacity. employees and have workers' 9. El Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. n We are a corporation and its 10.❑ Electrical repairs or additions
3 /!/ I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑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 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 DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Si a afore. _Al
A / • Date: '. 2
Phone #: 03 f- 5S 75 3 5
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):
I. Board of Health 2. Building D e p ar t men t Z. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other •
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
•
8.1 Licensed struction Supervisor: Not Applicable ❑
Name of License Holder,
, �, License Number
Address Expiration Date
Signature Telephone
y
9:`Re9istered Home Improvement Contractor ,,_, 4 .. ; i17, _ : , Not Applicable ❑
Company Name Registration Nu imher
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 ❑
1 1 V.. .omee,Owner xernptio -n
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 and ca oning Laws and State of Massachusetts General Laws Annotated.
<--" Homeowner Signature
•
•
W
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) R
New House ❑ Addition n Replacement Windows Alteration(s) n Roofing n
Or Doors 0
Accessory Bldg.* Demolition ❑ New Signs [D] Decks [El Siding [D] Other [D] H,
Brief Description of Proposed �+ L L _
Work: J / 4/ yg / �'
(
Alteration of existing bedroom Yes �o No Adding new bedroom Yes No } n „
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet i
6a. if < eW hous a ci or addition to housinq,tcompt to the f to f w 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?
7.
d. Proposed Square footage of new construction. Dimensi..:
e. Number of stories? .. ; ,f
f. Method of heating? 'replaces or Woodstoves Number of each
g. Energy Conservation Compliance. /111,_ Masscheck Energy Compliance form attached? ,.
h. Type of construction �'
i. Is construction within 100 ft. of wetlands? Yes _ No. Is .•nstruction within 100 yr. floodplain Yes No
a '
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 if
SECTION 7a OWNER. AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
� '
I, as Owner of the subject
property NIPr
hereby authorize Abb..
to act on my behalf, in all matters relative to work a prized by t . •uilding permit application. Ik'
Signature of Owner Date
I rTw �J " , as Own er /Autho
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my k
and belief.
Signed_ under the pains and penalties of perjury.
CA 's% \ O / ''
Print N
Signature of Owner /Anent Date
,,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required byZoning
N I This column to be filled in by AO' Building Department
Lot Size — �� VP ,
Frontage -- ---- --
Setbacks Front
Side L:' ? R:- -- L:__`. R: ,
---- i
Rear
Building Height
Bldg. Square Footage % _._
Open Space Footage _ _ _ _ % P
(Lot area minus bldg & paved 1 i
parking)
■ i i ? i
# of Parking Spaces
Fill: I 1 N
(volume & Location)
A. Has a Special Permit/Variance/Finding ever been issued for / on the site?
NO Q DONT KNOW 9 YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page ! and /or Document # ; I
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW OY 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 property? YES 0 NO 0))
IF YES, describe size, type and location: 4
s
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 4.
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, e,cavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO i
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
u .
^- `mow .._, t �`'' D�� #mouse anly t-a.� ^ **" _.i
'Iv) City of Northampton Staus # oPerm
" Building Department C it t rn e ray + = � - ` '
212 Main Street Sewe N 1 a 4-- IL - , - q - � - ` 1;
•
/ ,L a Room 100 1ri(ater�l(Ve11 l ai{a pity � �
' CZ" $ !�
Northampton, MA 01060 wn e ftrr, raf !p{ari
phone 413 -587 -1240 Fax 413- 587 -1272 4 *- 1an �
z° Q tt t er 5pecrf r
� --'"`� .APP CATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION 'r
1.1 Property Address:
This section to be completed by office
is-7 11 r���C)CCWC Dom" 611a f o f " " -- `Unit
p
/� / Zane x Overlay District
c% 1v
t;
Etm St. bistrict ` = CB D ist r i c t ` ,
`t
SECTION 2 - PROPERTY OW NERSHIPIAUTHORIZED!I AGENT
y
2.1 Owner of tRecord:
/ p n � ;
Q r I f T(A/Ay' DA 71`' 5 �N �'� ( 3—Ct>r` t�T V E' �'b «C t � `'�I/� ��U� �--
N ig nature
Vi
2.2 Authorized Agent: „ ;?
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 y CONSTRUCTION COSTS " ;m" `
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) "B ilding:`Perrriit Fee I°
2. Electrical
ki
( b),
Esti Cost of
Constru frarr> (8)
3. Plumbing B uilding Permit Fee:;, , .
it
4. Mechanical (HVAC)
5. Fire Protection (^
6. Total= (1 +2 +3 +4 +5)e�d �� Check Number
Th is` Sec For Of ficial Us Only:
Date
Building,Permit .Number - Issued.
Signature:
Building Commissioner /Inspector of Buildings Date
•
File #BP - 20130188 � ��1J� ' .
APPLICANT /CONTACT PERSON DAWSON CARL E & TINA M A C «fi;(
ADDRESS /PHONE 77 BROOKWOOD DR FLORENCE (413) 586 -7535 Q /tie 1/ -- ,,,--- ;
tt
PROPERTY LOCATION 77 BROOKWOOD DR :.;
MAP 29 PARCEL 392 001 ZONE
E '....---
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 17
Typeof Construction: CONSTRUCT 14 X 24 SHED
New Construction `
it
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included: : L
P
O i
wner/ Statement or License cii ;_
3 sets of Plans / Plot Plan tt<
#:l
rgx
THE FOLLO G ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IINFO ION PRESENTED:
,_Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§ 1
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 Penults Required:
I `
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 r
2 D ay
,.... 7 / A/ 00 01.1...
p• 7 .-2 3 - 72- --- i
< ,
ignature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning N-
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 & DeveIopment for more information.
!
77 BROOKWOOD DR BP- 2013 -0188
GIS #: COMMONWEALTH OF MASSACHUSETTS y
Map:Block: 29 - 392 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS °`
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: shed BUILDING PERMIT
Permit # BP -2013 -0188
Project # JS- 2013- 000270
Est. Cost: $8000.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groi p Homeowner as Contractor
Lot Size sq. ft.): 11020.68 Owner: DAWSON CARL E & TINA M
Zoning: Applicant: DAWSON CARL E & TINA M
AT: 77 BROOKWOOD DR
Applicant Address: Phone: Insurance:
77 BROOKWOOD DR (413) 586 -7535 0
FLORENCEMA01062 ISSUED ON :8/23/2012 0 :00 :00�
TO PERFORM THE FOLLOWING WORK CONSTRUCT 14 X 24 SHED
POST THIS CARD SO IT IS VISIBLE FROM THE STREET t
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:;.
Footings:
Rough: Rough: House # Foundation:
Driveway Final:
fi n:
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: = i
i
FeeType: Date Paid: Amount: 4;
Building 8/23/2012 0:00:00 X60
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck -- Building Commissioner