32A-109 CITY OF NORTHAMPTON
Constr. Lction Debris Affidavit
In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work
covered_by a Building Permit shall be disposed of in a properly licensed disposal facility,
as defined by M.G.L. c. 111 § 150A.
Address of Work: rE Ivv-41ktx-c-,T ^,e k.114/1,41-br/
The-debris will be transported by: Pkv-k.it TikttiR,
The debris will be received at: vAt-t-V1 601 CA"A'
fr
Signature of Permit Applicant
'Date V\ 1 :1)
Building Permit Number:
•
City of Northampton
� Massachusetts �w; * � �
v
1 � DEPARTMENT OF BUILDING INSPECTIONS ?i l 7°
.'e. a°' 212 Main Street • Municipal Building of ? ��J c..
N W• .,.-,�✓ Northampton, MA 01060 'sf+y` tit
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_regnire.cLcanDELAY the project until such time as the proper permits
and inspections are made
71 ,. A-01-7-4,-,4,... 6._ce-1.._sc_, understand-the above.
~
(Home owner/resident's signature requesting exemption) °~,.
I will call to schedule all required building inspections necessary for the building permit is ed to me.
Date �4 �G_ l� 'Z °"13
Address of work location S 4 l'"4d kt-, . Jr / 0(1-714,4".^,tv "--'
i
1
,,_,/
The Commonwealth of Massachusetts
�.. Department of Industrial Accidents
1��t�
` Office of Investigations
� j 600 Washington Street
* ��p. Boston, MA 02111
t^44 Ulf www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Name (Business/Organization/Individual): O^' / •-,Address: \ \ a \r-o ✓�) �, (r(tkr"
Please Print Legibly
City/State/Zip: f� lr�i.6/ � � , o l o G 1 Phone #: 441- JUS- �. 6s- j s` m--(33-.3
~
Are you an employer? Check the appropriate box: Type of pr ject(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
equired.] 5. ❑ We are:a corporation and its 10.0 Electrical repairs or additions
3.
iii am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
yself. [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.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners 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 ce- - under the pains and penalties of perjury that the information provided above is true and correct.
Signatur Date: kv G- k. r
moo\3
4 q So-Phon- #: 1" 1 3 S�S- c/6 c 215-1 c) .3 .)--)"
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
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 w Not Applicable £
Company Name Reg ation 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 £
Home Owner.,xemption
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 )eath)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you un•-r this permit.
The undersigned"homeowner"cc' fies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State d ocal 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) El Roofing ED
Or Doors 0
Accessory Bldg. E] Demolition 136 New Signs [D] Decks [E3 Siding[D] Other[D]
Brief Description of Proposed
Work: D&M AL_i tI o 1 asV i-r-fr--&' .r 140 At 6: 4
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ga If New house and_
Section 4. Zoe ING All Information Must Be Completed. Permit Can Be Denied Due To Inc.•plete Information
Existing Proposed •_■uired by Zoning `
is column to be filled in by
"nA Building Department
Lot Size -- -.- _
Frontage !._._._...__....___-_ __.._ ._____.._._......- ;�_.._._.. __....__....__._..._.__.._._..._.._._._ ..._........._......___.._--.--.._._.___.._._.._..._.s
Setbacks Front ., -i I_._...J
Side L: 'ZS R:O Liar R: :tir i I. 1
4:24 1I
Rear _....._...:_,
Building Height _ 1 "_,
Bldg. Square Footage 1 r_.__.-.__...., /o r__..-..__....... i _
Open Space Footage _, % r--- t 1
(Lot area minus bldg&p ed _._:..... .._..,_..._„ L.._..-..__.„t
parking)
1
#of Parkin- paces
Fi . 1 i
olume&Location) . `I `
A. Has a Special Permit/Variance/Findin ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Re ' try of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book j Page 1 and/or Document# I
erB. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO ei
IF YES, describe size, type and location: E 1
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,ex vation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
•
=4�-i 1; � k Depr�ment use only
r'L- \ City of Northampton Status ofPerm1t k n `ti �n t ''
20,3 Building Department Curb"Cut/DrivewayPermit i
vG \ 3 212 Main Street Sewer/SepticAvaitability° f
P P�cz otss Room 100 Water/Well Availab Ilty
Ns orthampton, MA 01060 Two Sets of structural Plans
' N�yp.--,,,,2 MP0060 p � h � r � �=
13EPNpFSNPMPT� phone 413-587-1240 Fax 413-587-1272 PIof/Site Plans " '
Otter Specify'=
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed ffice::
by o
1.1 Property Address:
1 MA& C r- s r(lc .r Map Lot Unit
i .iii ^. ( '(+ " ' r 0 1 0 6 0 Zone` Overlay District
Elm S1 District CB District`.
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: jill
Name(Prin 1 Current Mailing Address: qq
Telephone sic— '-S/C�
Sign re « ,' ZIS`- o-41 -4. )��
2.2 Authorized Agent: J �,�,/j l /�
^-'"f-1 t 4,�.,,.-- /'—► �c,/� d wiz" c9✓c /'�.p..r p U r< ��.�I C'�`-���
Name(Pri t) ' Current Mailing Address:
�- 417�—.T�1'- r9 41-- z/5--
d`9--6 3 ?..2....Sig re Telephone
CTION 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)Estim of
Construction ated Total from(6)
3. Plumbing Building Permit Fee Cost
4. Mechanical(HVAC)
5. Fire Protection
-__- 6. Total=(1 +2+3+4+5) �//O0 U _ Check Number
This Section For Official Use Only
Date
Building Permit Number: • Issued:
j' f�ff 3/13
Signature:
Building Commissioner/Inspector of Buildings Date
F6(( £LS�o I1 .
58 MARKET ST BP-2014-0160
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A- 109 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:INTERIOR DEMOLITION BUILDING PERMIT
Permit# BP-2014-0160
Project# JS-2014-000297
Est. Cost: $5000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 5749.92 Owner: 58 MARKET LLC
Zoning:URC(99)/ Applicant: 58 MARKET LLC
AT: 58 MARKET ST
Applicant Address: Phone: Insurance:
11 ORMAND DR (215) 869-6377 ()
FLORENCEMA01062 ISSUED ON:8/13/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INTERIOR DEMOLITION
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 8/13/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner