29-221 r`
O�i_m� ,T tiiZI:J 't ' ; _i - ---iz
I
DEPfRTMENT OF BUILDING jvSPFf r IONS 46 •
212 Main.Screet i Municipal B uilding
I NS P-CCTCR �.c✓
Norrb unp[on, MA 01060
iiv?' 01V�, LR JE_Xi NIP TION A C1,70NOWL ED(:FMFNT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as ;.is//her construction sup i or. the state defines "Homeowner" as, "Ferson(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-depart ment for the City
,.cofNorthampton wants any person(s)who seek to
use the home owner exemption, o act as their own construction- supei�isc-, 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 backTIN).
sonotube holes (before pour) a rough building inspection(before work is
concealed) i-asulatio-n._ins_pection (if reu.uired)and_a.final_buildina.insnectio.n. 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-wart; can-be.inspected.-
If the homeowner Hires other trades to perform work(electrical, plumbing&gas) the
homeowner will I 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
understand the above.
(Ho a owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me_
Date / - Zy
Address of work
location / / /d Y.� ✓r,� �L /fir
ck
The Commonwealih of AY_fessachuseirs
—T-- Department oflndustria.T Accidents
O[
4 77ce of In vestigazions
( 600 4'ashin,�ton Street
=; ,
Boston, AL402111
www.mass.g ovldia
Workers' Compensation Insurance Aftiaai-it: Builders/Contractors/Electricians/PIumbers
ADplicant Information Please Print Lesibly
Name(Bzsiness/Orzariza6on/7mdiviaual):
Address: // Z i�z rL c�3�-a sic y
City/State/Zip: t i; Phone.-:
Are you an employer?Check the appropriate box: Type of project(required):
4- I am a gene-al contractor and I
1-❑ I am a e�Ioyer with � 6. 7 New construction
employees(fu11 and/or part-time)-* have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached shee I?et_ � 7. 7 mode;n g,
ship and have no enploy ecs These sub-contractors have g- Demolition
employees and have workers' i
working for me in any capacity. 9- ,Building addition
rn wozkc s'comma.itisuance coma.>z a ance.=
10- Electrical repairs or additions
required.] 5. 7 riV e are a corporation and its
I am a homeowner doing al]work officers have exercised their 11,0 Plumbing repairs or additions
myself. [No work_rs' comp. right of exemption per MGL 12.7 Roof repairs
insurance rtquired-]t c. 152,§1(4),and we have no
employees. [No workers' �� 7 Other
comp.insurance retied.]
------* Pp - - -- --- -
tTriy ucan nct�ooz: trnrst also a out me set can oe:aw snowing thew workers'carrJ ensation policy infora>atioa.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors thal check this box mustattached an additional sheet showing the name of the suo-contractors and s=whether or not those entities have
errtpioyees. If the sub-concactors have ernploye-s,they must provide their workers'comp.policy numb=.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job sire
information.
Insurance Company Name:
Policy#or Self-ins. Lic.#F Expiration Date:
Job Site Address: City/State/Zip.
-attach a copy of the workers' compensation policy declaration page(sbowina the policy number and expiration date).
Failure to secure cover age,as required under Section 25A of MGL c. I52 can lead to the imposition of criminal penalties of a
fine up to S1-500.00 and or one-year imnrisonn OR
ent, as well as civ?penalties in the form of STOP WORK DER and a fne
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
Investisations of the DLk for insurance coveraze ver(cation.
I do hereby cert<,fy under the pains and penalties of perjury that the information provided above is true and carrect
mate: t`J
Phone#
QUxuu use only. vo not wrzte in this area, to be completed by citr or town offzciaL
City or Town: !! /7 - Per-mii/Lice3se i 4--
Issuing-kuthority(circle
1.Board of Heaith 4uilding Department. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6. Other
Phone
-
Contact Person: :
o
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Appliable ❑ •
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Registered Horne Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 452,§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-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
M
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
o .R
New House ❑ Addition 'F�g Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding[O] Other[ED]
Brief Description of Proposed 10 X
Work: lZ E-'N a V T, 157,1,r Lr4 r14
D�'�$'G�.� it%l1.Jrv1� ,��O��f�u� �/X/5'j✓u(� IL �'1'Z•rf-�1�
Alteration �crsti�j�edroom Yes G No Adding new bedroom Yes No � /
Attached arrra v`e Renovating unfinished basement Yes y No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
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'
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 Name
11 "/V
Signatur , f wner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required bygioning •
This column tore filled in by
�7 Building Department
Lot Size �.� - �"�'L ..,.
A�
Frontage .,
Setbacks Front
Side L:3S R: .! D-+ L: X72.,: R: . �
Rear 52 3
Building Height 2d Z v �.3 t5 J
Bldg. Square Footage %
Open Space Footage p %
(Lot area minus bldg&paved L.0 !Z3 vo_'q3 f
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q Date Issued:
C. Do any signs exist on the property? YES NO
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. WII 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 NO
IF YES,then a Nort hampton 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
Room 100 Water/Well Availability
Northampton, 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: hi )ction to be completed by office
C
ap lilf' Lot Unit
i
FEB ZME9 Overlay District
r-e n c-t
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZE AGE` OF L()IN y'sY 01060
2.1 Owner of Record: 1.
9 . - "I f� ��I�C�L�� 411 �� �Z /7��f L y',-�J-06 �c 1� P OE
Name(Pr t) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-'ESTIMAT,ED CONSTRUCTION COSTS'
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical /L ,, (b) Estimated Total Cost of
Construction-from-(6
3. Plumbing "- Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
0. T�lal-(1 i 2 i 3 i i 5) L Z0`� (:hank Niimhar
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building o---- or/Ihpctofiudgmmis eBi ate
File#BP-2008-0699
APPLICANT/CONTACT PERSON HATHAWAY RAYMOND L&PATRICIA
ADDRESS/PHONE I I#A� ZOOK DR FLORENCE (413) 586-0964 O
PROPERTY LOCATION 112 ACREBROOK DR
MAP 29 PARCEL 221 001 ZONE URA/WSP
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 10 X_23 SUNROOM W/14 X 23 SUNROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildin_Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF96MIATION 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.
City of Northampton l ! J
�Mr BUILDING INSPECTION LABEL
<
OVEn
Inspector
v ` ��� a a a a' y Date
WS,£
k # ��
� 4
�a
,F
h
J }
e�
t
F �
mot,
X
_ ku
u t
zg
F
112 ACREBROOK DR "
GIS#: COMMONWEALTH,"," ko �
Map:Block: 29-221 CiTy
kl-
Lot: -001 PERSONS CONTRACTING WrMl UN'
Permit: Building DO NOT HAVE ACCESS TO TH fi�
Category BUIL"Dn", G
Permit# BP-2008-0699
Proiect# JS-2008-001083
Est. Cost: $16200.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg. ft.): 10018.80 Owner: HATHAWAY RAYMOND L&PATRICIA
Zoning: URA/WSP Applicant: HATHAWAY RAYMOND L & PATRICIA
AT: 112 ACREBROOK DR
Applicant Address: Phone: Insurance:
112 ACREBROOK DR (413) 586-0964 O
FLORENCEMA01062 ISSUED ON:212812008 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE 10 X 23 SUNROOM W114 X 23
SUNROOM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
luspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter: OK 0 61 o y' 01 C&A I i
Footings:
Rough: Rough: JP_ House# Foundation:CK 6 . J6,eg'
Driveway Final:
Final:: Final:
Rough Frame�k
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
a B��o9 v9 (,a�tts
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc si nature:
Fee'Type: Date aid: Amount:
Building 2/28/2008 0:00:00 $50.00321
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner- Anthony Patillo