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Building Inspector 1 ------
212 Main Street
Northampton MA 01060 JUN 1 20U9
;j
To Whom It May Concern:
The garage on my property at 383 Brookside Circle will never be used for living space.
Diane L. Seaver
383 Brookside Circle
Florence MA 01062
r
c
9�101
JANICE C. ARCHADExpiras
Notary Pub
COMMONWEALTH OF MASSACHUSETTS
My Commission November 12,
Lz#y zyfnzlnzn z
�IIdEEH CItliEtttE
" DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building
y S
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as 1.is/her construction sup,. :.- 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.
(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
The Commonwealth of Massachusetts
Department of In dustrial Accidents
Office of Investigations
d 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibly
Name(Business/Organization/Individual):
Address: �j
City/State/Zip: T_Iore,cc Phone.#: 22
7�if you an employer?Check the appropriate bog:
Type of project(required):
4. I am a general contractor and I
1.❑ I am a employer with 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 g. Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp. insurance. 9. Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.[J I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
Any apphcan that checks ox 41 must also fairout the section below showing their workers'compensation policy information.
t 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. #: 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
Investifzations of the DIA for insurance coverage verification.
I do hereby eerti and thepains and nalties ofperjury that the information provided above is true and correct
Sim afore: Date: r'
Phone#: y�3 _s�'��/ 7 D
r al use only. Do not write in this area,to be completed by city or town official
r Town: Permit/License#
g Authority(circle one):
rd of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERIICES
8.1 Licensed Construction Supervisor: Not Applicable El Name of License Holder: ��cJe7 `t-`�`�L'�-5 pl�'3ab-��/y
License Number
Add s �e�/ Expiratio Date
7
Sig a r Telephone
9-Reafstefed Horr 0rnproveimerit Corifraetor _m e4 .�; ? _ Not Applicable ❑
Company Na Registration Number
Address E
xpiratioh Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE,AFFIDAVIT(M.G.L.c.1,52,§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-0W:>1ler Exe *
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
J
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition [Z Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition New Signs [I]] Decks [[] Siding[E3] Other[[21
Brief Description of Proposed
Work: >(/;, -0e �17X Rte.
Alteration of existing bedroom Yes No Adding new-bedroom Yes _No
Attached Narrative Renovating unfinished basement Yes _Y No
Plans Attached Roll -Sheet
sa._If New house°and or-additibin to 6khAinci`tioiis na:-camptete the fotiowir a:
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? ,y e_.
d. Proposed Square footage of new construction. .4� Dimensions
e. Number of stories?_ f
f. Method of heating? /Vo it e 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 o. s cons ruc ion wi i Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
1. Septic Tank City Sewer_ Private well City water Supply,_
SECTION 7a-OWNER AUTHORIZATION-701 BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING,PERMIT
I, N I f—t l� 5 ��� R 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 Owner Date
.C/vv/w as Owner/Authorized
Agent hereby declafe 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.
I S.
Print N e
Signafu4g Owner/Agent I 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 jgg
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved
, .
#of Parking Spaces
(volume&Location)
A Has a Special Perm it/Variance/Fi nd ing ever been issued for/on the site?
NOG DON'T ...~.. +~� .^~
IF YES, date issued:, /
IF YES: Was the permit recorded at the Registry of Deeds?
��
NO �� DON'T KNOW ,o
IF YES: enter Book Poge� and/or Document#� |
�� ��
B. Does the site contain ubrook, body of water urwetlands? NO ��j DON7KNOVV «�� YES �~�
IF YES, has permit been or need tobe obtained from the Conservation Commission?
Needs tobeobtaiomd v,� Obta�oed v~~� Date
� ! /
v�� �~� ' ^
C. Du any signs exist nn the property? Y[3 0 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 x~� NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre oriud part ofo common plan
that will disturb over 1acre? YES � l NO 47)
�� %4y
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Qepartmenii use onEy
City of Northampton status ofPerm�t' `
Building Department Garb CeDnvernray trerni
212 Main Street Seth- ep�cAvaildbility
--' Room 100 Vater/V1le[I AvaitabtE
�rthampton, MA 01060 Tvua Sets ofStru'cfuraCP
(� fans s
hone 413-5$7-1240 Fax 413-587-1272 Plot/SEte Pians
M A ` Other Spec,fy
APPLICATION TO dl UCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
r
SEC FAN 1=SITE INFORMATION'
1.1 Property Address: This section to be completed=by office
Map Lot Unit
Zoner Overlay District.-
Elrtt St.District ' ':Z13-District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: C
', c Sj;sgel
Name(Print) Current Mailing Address..
Telephone
Signs ure
2.2 Authorized Agent:
Name(Print), Current Mailing Ad Kss.
RgY--12 7 J .2 S'.3
Signa(urV 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 mp
6. Total=0 +2+3+4+5)-
4+5) ��. ' Check Number
This Section For Official-Use Only
Date,
Building Permit Number. Issued:
Signature:
Building CommissionerlInspector of Buildings Date
File#BP-2009-1002
APPLICANT/CONTACT PERSON DOUGLAS ANDREWS
ADDRESS/PHONE 89 LONGVIEW DR FLORENCE (413)584-1370
PROPERTY LOCATION 383 BROOKSIDE CIR
MAP 29 PARCEL 260 001 ZONE URA(100)//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:_CONVERT tXISTING 10 X 12 DECK TO SUNROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License 078947
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I F 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 Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Bui ding 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.
a
BP-2009-1002
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
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-2009-1002
Project# JS-2009-001443
Est. Cost: $18000.00
Fee: $108.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DOUGLAS ANDREWS 078947
Lot Size(sq. ft.): 18556.56 Owner: SEAVER DIANE L
Zoning URA(100 /)/WSP Applicant: DOUGLAS ANDREWS
AT. 383 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
89 LONGVIEW DR (413) 584-1370
FLORENCEMA01062 ISSUED ON.612412009 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT EXISTING 10 X 12 DECK TO
SUNROOM
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 6/24/2009 0:00:00 $108.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo