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DEPARTMENT OP BUILDING INSPECTIONS 1 _
212 Main Street ' Municipal Building r P G �=—
Northampton, Mass. 01060 WA`-.,
WO-RICER'S COMPENSATION ENSURAN A FITTFMV1T.
• (Ii ccasccipermi tt'cc)
with a principal place of business/resi. nee at:
• (phoney)
(sr:r=lici statclzi.
do hereby certify, under the.pains and penalties •f 'erjury, that
( ) I an an employer providing the followine 'orl, is compensation coverage for my
employees worUng on this job:
.
(l strap Corer. r) (Policy Nu-nbcr) (E:-pinion Date) .
•
( ) I am a sole proprietor, general •retractor or homeow-ner ( ;rcie one) and have hired
the contractors listed below wbo 've the following worker's co -'oen_cetson policies:
•
(Nam:: of Con tracio ) (ln ur ono.. Coinpariv?oUCi l'quinhc:) (F.`:pirat3or: D1tc)
(Namc of Conlraor) (1.nstraps:: C.omnaa,;rPo!icy Nurnc_r) (LZp•.:lion Dale)
(Name of Coazza•or) (Insurance. Company/PoUc}• Nu.sb::r) (Exairdoo *alt)
I
(Na.mc of 'naactor) (Insuran Company/Policy Numbs-r) tE.tpiradan D.
(aZah_dutioc 1 -, ilnccc+--ti-to'c-,dv.&infor loo pctcioiag to..11 mcr--.corn)
( ) I am a sole proprietor and have no one working for me.
( ) I alma home owner performing an the work myself.
NOTE:p1--44 be"'"arc t4.4.w:::-.1;c bccco.iac.a uto splay --,,pay to do r- •,--,cs=oo c hair'work oa a dwr-Ili^;,of
W34 toots L13;..A t�tr_'Mitt in W th the bot000twc muds or oa the pvunett z7pt:zteat.—tbeeo c-t W[E-.=. oecdeoi to be
citploy c-z tto the wo tr?:c=p.... +ioa A=(G12152=1(5)).o•,-pLi on by a bozo x f •t ti -‘c a pc-mit=ay t icks the
icgal clams of ea 4loy.r uodar tlso Worcoet Coospa .. on Act_
I uodc o4 dad a copy of tbir cntcmoat may be to r-..o d.4 to tba D pnrtmo.1 of ladtisric!Accdcros'CQoo of loaur.00a rot tb.
ooveab�c t c;6toion sad lb=Lilsa-n to Loa=toventse',net-.=aioa 25A of MOL 152 lac lr to the in:pasition of cimiaxl prr ltia
ooavz.mg of a floc of t 1 to S 1 500.00.ridfor iscrprboazocIt of up to ooc yr1 tad=rill pantos in 6c form ore Stop Wort Ord=and a
fig of S1.00.00 t city a.i..4 tuc..
For doper. 1 u,c only -
Pc-rmit NU Ibc
.Adap" LAt„ I i
S;j latat,-t ofLic=r_u:JPcrmitrcr_ Lace I A
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DEPARTMENT OF BUILDING INSPECTIONS , _.E��/;
INSPECTOR 212 Main Street • Municipal Building '�
Northampton, MA 01060 `,
e"
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sups:,:sor. 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 affil ng 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 backfiIl),
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 DE - ' : proje such tim the proper permits and inspections are
made • iv -
I, tti , a1/4)\ Lk) • ' s -ii-e 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 1 &)v O
Address of work
location 7jØ FL-ok6Nc& Rey D
f ove;vte, IWN 010(92--3607
' 4
SECTION 8 CONSTRUCTION SERVICES f-•
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
912s T§tereet-tTomg riiiik veinent.Goiifracto a ., 1 : :4:C . $ Not Applicable ❑
Company Name Registration Number
,ddress Expiration Date
Telephone
SECTION 10 WORKERS'COMPENSATION INSURANCE.AFFIDAVrT`(M.G L.c.152,S25C(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 ❑
-..:,,ia-4, 447.-7 -ZS06-17417. .'' ' ,,,,:- .A
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 aII 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"homeowne " - ifies and es responsibili tr compliance with the State Building Code,City of
Northampton Ordinance-, tate an. LocZonin Laws and S S . Massachusetts General Laws Annotated.
Homeowner Signat re t A4i' - - - .� // - /!lam'
Fr
r
4
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑:;: Replacement Windows Alteration(s) in Roofing ❑
Or Doors 0
Accessory Bldg. ® Demolition ❑ New Signs [El] Decks [[] Siding[t7] Other[0]
J Brief Description of Proposed rL 'E_ p� 'F A 6 5.1.1a lox(
J� Work: ! I 'I
Alteration of existing bedroom Yes No Adding new bedroom Yes Y No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
,,;. .�.� �+.s- y. �'�,,. �.'- h 3r' r'ak ""5'�::' s-:,h.�Y`" »S�.:,ra.°''�..�` 'u � ^e.�,:. ^^ t� "5^.a'�?+u'
sa_it- a f- ro"' sg-an c g dd>a t&T nc fajiictc �_cor 6fgiaii u E q:
a. Use of building:One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
k. 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 AGENTOR CONTRACTOR APPLIES FOR BUILDING PERMIT
,as Owner of the subject
property
Xhereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
— 4,4„,,,,
5 I, r, _ A Air 11..■■ ' ''.4.�' ,as Owner/Authorized
Age rer by decl. a tha he st. '• wand information on the foregoing application are true and accurate,to the best of my knowledge
and •elief.
Signed under the pains and penalties of perjury. ',e-Nt :\1-24
.G.., ,Slif iA,e— C.?6--"z:41-5{-
Prin ,ame /'
Si. // "7/0....---
a e of Owner/A nt
�" Dae
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 r S i
Frontage — ! ` ` ' i
Setbacks Front j
1 Side L:�. : R: ` 'L' : R: - A
V I L._10
Rear
Building Height i`-(U-' '_ ,/~
Bldg.Square Footage
Open Space Footage -�� %
(Lot area minus bldg&paved I J - ! 1 I A)A
parking)
i
#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 e YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW e YES 0
IF YES: enter Book : Page:; 1 and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission? '
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES I@ NO 0
IF YES, describe size, type and location: i___
D. Are there any proposed changes to or additions of signs intended for the property? YES i NO ID
IF YES, describe size, type and location: 1 !
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q r NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
■
City of Nortt��mpton �� SPe
$uilding Department '` p. �e i� �
212 Main Street Sver t
Room 100 '
Northampton; MA 01060 7-v. fs.5fc etira � � - ,
phpne 413-587-1240 Fax 413-587-1272 TIat.S�'fans �4 ,�. _
F �,I 9flle pectrY: ^ s� '. 'i �=
APPLICATION TO COI�STRUT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION1.-SITE:INFORMATION
1.1 Property Address:
This seetron�to be c
ompfeted by office
Map O3 x Lot `i ' fl unit
V .7 10
�C�n.FN�F � fy
Zane Overlay Dtstrrc:t
{t L
Eln SL District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
't�,1e °hs`r Mkt) e Gv 12 2 Fdoc�ev\ee.. PoorA
NftLfr(Print) Current Mailing ddres
c ) i - 1 — ' 3 10 — 2�.°e %� �� (��—a Tel phone
Pgna ure /
2.2 Authorized Agent: _ , _ 0.2,0,..„
yr ,�� � I.
�'7 !O o tf`r_��r` e da
Nam- ��� Current Mailing Address:
EnC-'4"TI Te lephone
ON 3-ESTIMATED CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
t completed by permit applicant
1. Building }t' 3 6 S� (a)iBuilding Permit Fee G o
2. Electrical Cl! (b)Estimated Total Cost of
A Construction from(6)
3. Plumbing Building Permit Fee. `
4. Mechanical(HVAC) 5-,v�
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number �V/ ? �r} —
ThisSection For Official Use Only
Date
Building Permit Number. -Issued:
X
Signature:
1
Building Commissioner/Inspector of Buildings Date
File#BP-2006-0518
APPLICANT/CONTACT PERSON BIBLE BAPTIST CHURCH THE
ADDRESS/PHONE 722 FLORENCE RD FLORENCE
7104'
PROPERTY LOCATION 722 FLORENCE RD
MAP 37 PARCEL 018 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid /017 f s Ps--
Typeof Construction: ERECT 10 X 16 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:§
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 ommission
4////el
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.
722 FLORENCE RD BP-2006-0518
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:37-018 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0518
Project# JS-2006-0767
Est. Cost: $3465.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 214750.80 Owner: BIBLE BAPTIST CHURCH THE
Zoning: SR Applicant: BIBLE BAPTIST CHURCH THE
AT: 722 FLORENCE RD
l ppiicont Address: Phone: Insurance:
722 FLORENCE RD
FLORENCEMA01062 ISSUED ON:11/14/2005 0:00:00
TO PERFORM THE FOLLOWING WORK:ERECT 10 X 16 SHED
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:
din:'•: Sm.ke: Final: 6 f4 Louk ilAssii.pvc-
Sh0 ,7165'
THIS PERMIT MAY BE REVOKED BY THE CI ' OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULA IONS.
Certificate of Occu'am Si.nature:
FeeType: Date Paid: Amount:
Building 11/14/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo