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4. DEPARTMENF OP BUILDr)-,',G INSPPCTIOI:S —
212 Alain Street Municipal Building
Northampton, Mass. 01060
W O M'CE R'S C O N/IP ENSA T70 N M S URA_N CF Al,IiTJ�t' vj-I'
(IiccvsxJpertn�ttcc) __.._ _--
v.,ILh 2 PI-mi cipal placc orbusiness/residence at:
OXVo,..
(Srr=Vei ty/sta iel�p
do hereby certify, under the pains 2nd penalties of perjury, chat
( ) I am an employer providing die follolvine lvori-Cr'S colnnc)sZUo, cove agc For Iny
etnplovecs woriDing on Oils job.
(iesw-� Conn n�) (Pelic;
( ) I am a sole prooriccor, general contractor or homeowner (ci;cie one) and Lave hired
the couu-actors listed below who have the foUol�ine workers COGJent26on policies:
([+alIle Or r0_^.r::`-Ci0") (t I1R!r311C.C. COInDaII}";PGUC',' >�ru.(TICCr) rt-_>:)liJUn1 I�:1lC)
- (Name of ConQZetor) -- (Insuzne CotnDaa}iPolicti \, ,LLm rr) t."t.Lmilon Date)
(Name of Connaczo;) (aau`aDe;Compao)•fPobc)- N mbu) (Expim6on Date)
(Name of Contractor
(Lrintran ComcalryfPolicY Numbr) (Expiration Darr).
(aaaC�l-3dit:ocal rtk-cl.if to mdudr infbnmA.7oc pct�w.L oo,tn�) i
i?
I am a sole proprietor and have no one w 1;3og for me r 1
0 .
( ) I atn a home owner performing all the work myself-.
NOTE:plccc be cwan[h••uj Ic bcmco,vcn u{�o cccPIQy pcioas m d&r+ r• .` �c��s c� o cr m av worx an a d�.cll-g of
aN mot tt_"_O L.tTTr Dart la K':'n LfK 6=10 ocr r=db Or cc lb• p-o�j zl purtc •r-1 t LT DJ(�/v•.tIY 0.^Ct:[ Rj ID t.Y
citploy ua c the o i dz o y�qcl(GLI 52-S 1(5)Z apptiatioo try a bomrnava fcz c bc=_cc pmnir,=y cvidca«U-
Ieg!r-i_.of under dw Wo,E 'Coo�pem.tion AcC
I uodcmumd dxe>oopy of tbi.=_11_1 may bo(,Oc-..nrd-d to ti,
Dgxnmc:oc of Ind+.,.tlicl ncvdm&Olroo oC for the
covc> vvZarlioo nnnd au-i L,.JLzt to tco_ut l•.o`cm�under lcctjoa 23A of MOL 132 can Id to the impoiilioc of crimia.',pcaillio
000v_siag of a tine o(Vp to S 1_�00.00 ardtor or up to ooc yr3r and civil pcnahio is tx roan ora Slop Woric Ordcs and,
fim o(S I oo.00.d_y ap,ina m�
For 6cpartri,l.i u.c on7y
Pcrmit Numbcr
_ 1 ► `�� N/Lnpv _ Lot .
SiE-)a-1 turt of I-iC=ISC�criniucc —U�ir-e
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municiptl Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction supc_:, 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 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
I, understand the above.
(Horne 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
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder: 1� C-� L ) _�� q
License Number
Address Expiration Date
Signature Telephone
9.Re' istered Home lm rovement Contractor Not Applicable ❑
. IS `a--
Company Name Registration Numb r
� � � �� s LA P l -1 (0
AdcTress —� Expiration'Date
Telephone q 13 SX)-, )
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...... ❑
11.- Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellines 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 buildine 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 reterence 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [p] Other[E I
Brief D ription of Proposed
Work: hI�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
d mee the following:6a. If New house and or adition g
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
s �
I, O as Owner of the subject
prope
hereby authorize \\(j
r \
to act on my behalf, in all matters relative to work aut i�orized y this building permit application.
Signature of Owner c Date
e
as Owner/Authorized
Agent hereby declare that the statement§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.
r
Print Dame
Signature of Owner/Agent Date
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
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage --7 %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Variance/Fi nding ever been issued for/on the site?
NO t J DON'T KNOW 0 YES � 1
_ _
IF YES, date issued'
:L_--__�_____�
IF YES: Was the permit recorded at the Registry ofDeeds?
( ) DON7KNON/ � N
NO
_ _�- _
IF YES: enter Book --------- rage�-�---=��--! and/or Dncument#
--- ------
B. Does the site contain a brook, bodyofwmterurwet|onds? 0O y—� DON'T KNOW /—��� YES
U,
IF YES, has u permit been or need to be obtained from the Conservation Commission? �
Needs to be obtained ~~�/~� Obtained �-\~�� Date --/
' � �
—[o-any prUpertY?--YES- — - 8O-�- - - --�����--
IF YES, describe size, type and location: | '
D. Are there any proposed changes to or additions of signs intended for the property? YES /—� NO
IF YES, describe size, type and location: � -------}
E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre orieh part ofa common plan
that will disturb over 1 acre? YES �� NO
��
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Ststus of Perinit
Building Department urb�Cut/Dnuevay=Permit
UCI —212 Main Street SewerlSepticallabzllty
Room 100 tNter`1>ti1e11vaIa1111�ty `
_ Northampton, MA 01060 Tv!o Sets of 5truetural Pdaras
p�horV 4;1 87-1240 Fax 413-587-1272 PIotIS►te fans -
Other'Sjieci,
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address:
This section to be completed by office
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
f 1c a.Y' 0" =I '% 1 YN t �_1
Name(Print Curr ling Address:
O
c" Telephon `
Signature
2.2 Authorized Agent: -�
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection Wr 04 A9
6. Total=(1 +2+3+4+5) b® cl:> Check Number
This Section For Official Use Only
Building Permit Number: IIsssued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2007-1132
GIs#: COMMONWEALTH OF MASSACHUSETTS
4° CITY OF NORTHAMPTON
_,x
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2007-1132
Project# JS-2007-001805
Est. Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 152172
Lot Size(sg.ft.): 13982.76 Owner: MAGGIOLINO LEONARD A&PHYLLIS
Zoning URA Applicant: BOB THIBODO ROOFING & SIDING
AT. 36 BEATTIE DR
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527-7663 ()
NORTHAMPTONMA01061 ISSUED ON.511812007 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP 1 LAYER & SHINGLE ROOF
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 5/18/2007 0:00:00 $25.00949
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo