29-117 (2) BUILDING PERMIT PLAN
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PLAN OF LAND IN
NORTHAMPTON , M ASSACH U SETTS
PREPARED FOR
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ROBERT AND LINDA JACQUE
RAND ALL SCALE: 1"=40' MAY 7, 2008
E. HAROLD L. EATON AND ASSOCIATES, INC.
IZER N REGISTERED PROFESSIONAL LAND SURVEYORS
935032 ' 235 RUSSELL STREET — HADLEY — MASSACHUSETTS
RV � 413-584-7599 4i3-585-5978 "fax)
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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
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
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
. � t
-* The Commonwealth of Massachusetts
x Department oflttdustrial.4ecidents
-- Office of Investigations
' 600 fd7ash.ing ton Street
Boston, MA 02111
_ - n,tti'w. nass.gov/dia
Workers' Compensation Insurance Affidas-it: Builders/Contractors/Electricians,/Plumbers
Applicant Information Please Print Lesibly
Name (Business/Organizarion/Individual):
Address: .Z f} U z_Cy_
City;/State/Zip: 1"o-ITtt 1 Lt., 616(,o Phone#:
Are you an employer'Check the appropriate box: Type of project(required):
I.❑ I am a em to er with 4. N I am a general contractor I
employeesp(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in an y capacity. employees and have workers'
5 P ty 9. RJ Building addition
[No workers' comp. insurance comp. msurance.-
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ lam 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.❑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 III must also fill out the section below showing their workers'compensation policy information.
r 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. #: �f i�t•' (o L l '1 ("1 KVU Expiration Date: 10 iS o
_ (_ ,�I
Job Site Address: rt1/uZS 1 G(A? d'' ) - City/State/Zip:Aj`+tT n i��J./ t ®(vu()
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$L500.00 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. 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 tify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone#: I:— (2
Of use only. Do not write in this area, to be completed by city or town offciaL
Citv 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 n:
s � r
SECTION 8-CONSTRUCTION SERVICES
I
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: T t J ��'�l ��✓L- 4 G�� _ �
License Number
Address Expiration D to
Signature ` Telephone
9.Registered Tome Improvement Contractor:-,. :.M _ Not Applicable ❑
lv3CtL I
Company Name Registration Number
04L) ry"L ( R/L t7 '7 110t0`l
Address J [ Expiration ate
71 L/✓�}L) L , jy /'L?W Telephone; �O u
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G L c.152,§r25C(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....... Ji No...... ❑
11.-Home.Owner aempti on
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-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
t
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ® Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors F—I
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding[p] Other[0]
Brief Description of Proposed
Work: h o 0
6191 r!
Alteration of existing bedroom Y_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ga. If New and or addition to existing housing; complete the fo[[owinA:
a- Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a--OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,
as Owner of the subject
property -
hereby authorize
to act on my half, in all matters relative to worts authorized by this building 4eit application.
re of w er 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 Name r�
i
Signature of Owner/Agent Date
3
Y
Section 4. ZONING I Aii 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
9
Side L: R _t_�.�.,��_ L: R..n�'�.� ..w.
Rear
Building Height
Bldg. Square Footage u Y t
Open Space Footage
__.
(Lot area minus bldg&paved
parkin )
#of Parking Spaces
Fill:
(volume&Location) ----- -A. Has a Special Permit/Variance/Finding 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 Registry of Deeds?
NO 0 DONT 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 0 DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued
C. Do any signs exist on the property? YES 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 0 NO 0
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 pian
that will disturb over 1 acre? YES 0 NO M
IF YES,then a Northampton Storm Water Management Peimitfrom the DPW is required.
Department use only
City of Northampton Status of Permit:.
Building Department Curb Cut(DrivewayPermit
212 Main Street Sewer/SepticAVailability
Room 100 Water/Well Availability =
Northampton, MA. 01060 Two Sets of Structtical Plans
G M AY 1 3 �2 one X1,3-587-1240 Fax 413-587-1272 Pldt/sf6 Plans
Other Specify
APPLICAI�Or >rON T UCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
i
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:G2 �a CL ��i� x✓� Map Lot Unit
Zone Overlay District
Ft 0 UL(?4-,'C,
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Ma vi LU x o 9—u�°- -Q l�1 T�v FIQ)0�jQ /Y1�01d�2
;Name( ) Current Mailing ddress:Telephone
gnature
2.2 Authorized Agent:
. /A V t'1 -0k>L7L I +Ai;A CIL :Jr Te:���t
Name(Pry ) Current Mailing Address:
—q1(4- LZ a
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS-7
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building C/Cj tl . /t�, (a)Building Permit Fee
2. Electrical tt / cam•' (b) Estimated Total Cost of
3306' 06 Construction from(6)
3. Plumbing uU Building Permit Fee
4. Mechanical(HVAC)
C C`
5. Fire Protection
6. Total=(1 +2+3+4+5) EGG. CC; Check Number � t �
This Section For Official Use.Onl
-Date_
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspectorof-Buildings Date
File#BP-2008-1013
APPLICANT/CONTACT PERSON David Fortier
ADDRESS/PHONE 32 Laurel St NORTHAMPTON (413)586-8965
PROPERTY LOCATION 88 FOREST GLEN DR
MAP 29 PARCEL 117 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out C:4 oc 44
Fee Paid
T_ypeof Construction: CONSTRUCT 22 X 14 MSTR BEDROOM/BATH ADDITION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 008026
3 sets of Plans/Plot Plan
THE FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOYAATION 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 Co ssion 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.
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88 FOREST GLEN DR BP-2008-1013
GIs#: COMMONWEALTH OF MASSACHUSETTS
Ma :Block:29- 117 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: BUILDING PERMIT
Permit# BP-2008-1013
Project# JS-2008-001516
Est. Cost: $49700.00
Fee: $154.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: David Fortier 008026
Lot Size(sq. ft.): 14157.00 Owner: LUCEY STEVEN E&
Zoning: URA Applicant: David Fortier
AT. 88 FOREST GLEN DR
Applicant Address: Phone: Insurance:
32 Laurel St (413) 586-8965
NORTHAMPTON MAO 1060 ISSUED ON.512012008 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 22 X 14 MSTR BEDROOM/BATH
ADDITION
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: O�
Rough:�� _03�X Rough: /?�b7 House# Foundation:
�°C/ Driveway Final:
Final: �^-�� � ���;,�nal:�•a'b,(jg'
Rough Framga*k 7 1,4��8
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:OA—o-011ew- 4ac/i
Final: Smoke: Final: Old of f 14/07 6ct t s
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA N OF
ANY OF ITS RULES AND REGULATIONS. % _
Certificate of Occu anc 11-1111f Signature: (/
FeeType: Date Paid: Amount:
Building 5/20/2008 0:00:00 $154.005247
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo