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SECTION 8-CONSTRUC710N SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
T
Name of License Holder: �,J i4'W` e.S
License Number
Address Expiration Date �,
Sig a re Telephone 2 a
I �-
e is i e . orneti ne a ontrac- Not Applicable ❑
Company Name Registration—Num er --
Address Expiration Date
Telephone
SECTION 10-WORKERS'CQMPENSATION-INSURANCE AFFIDAVIT(M.G:L.c.=152,425C(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...... ❑
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 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 Z nLaws and State of Massachusetts General Laws Annotated.
Y
Homeowner Signature ^`
r
L
SECTION 5-DESCRIPTION"OF.PROPOSED WORK(check-all applicable)
New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [p Siding[O] Other[dj
Brief Description of Pr posed VN
Work: Z 'J c1
S
_.
Alteration of existing bedroom Yes—�4,—No Adding new bedroom Yes N.
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
.r�<, ya., «avzrv^ a :*r° rt"':.nR '€, .. .. �e_.•r0.':•®�„°'"” -c+Y�'�3,'�"„'° °.x`s�"k .-�"'€"d', -=5�.?':
sa l�I�evu�oase'� .,� dd>�t�ra�ce� c�o�usincl.�-cdmglet�#h � nu�rur4:
a. Use of building:One Family Family Other
b. Number of rooms in each family unit: Number of Bathrooms 2
c. Is there a garage attached? - 16_
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? �^ i
f. Method of heating? 1��e_C. "'r t C Fireplaces or Woodstoves 6OL4t Number of each
g. Energy Conservation Compliance. n0 Masscheck Energy Compliance form attached? rl
h. Type of construction W v J
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 -�;— 'C—Il-
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNERAUTHORIZATION-TO BE COMPLETED WHEN
OWNERS.AGENT,OR'-CONTRAC,Tl—. a PLIES 0 OR26UIC6I43 PERMIT
r(� Gl J� ,as Owner of the subject
property I �
hereby authorize Ck V1^ '+M C(1\ `-s
° ' t'► '`1
to act on my behalf,in alj,matters relative to work authorized by this building permit application.
Sig ture of Owner
Date f / O
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.
1 3Na S /
wner/Agent Da
�'St1AMP�.
C-x#V of Nart4aniptan z
a -
1835AC}t3[B[tt4
` DEPARTMENT OF BUILDD1G INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building o
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 sup ~,isor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or-twzi fami __-
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."
Thebuilding department for Me 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 DELAY the project until such time as the proper permits and inspections are
made j
/�
I, + � 14 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
1
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Crii� of Torf Z1uII)foil
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DEPARTMEWT OP BUILDr�,,G INSPECTIONS -
212 Alain Strect Asunici al Duildin
I � g
I Northampton, Mass- 01060
I
- WORl=.R, C0ITPENSA=0N GgSU ACE a.l F1-I�ri��17'
(lice- s Pc-rmiltcc)
%frith a prLZcipal place of business/residence at: -
I
(sv��tlaty/sza.tc.np)
do hereby certify, under the.paim :md penalties of pc9UFY, =.hai
( ) I am an employer providing tale follo.ving'%vorker's comocnsadon cove age for my
1 employees vvori6ng on tills job:
Omsunan=Comr.:ay) (Polio: Nu-mbcr) — ( :-pirdor.Dom)
I am a sole pro pr-,etor, general contractor r horneowoer (c c:e one) and have hired
the contractors list- below c wing worker's comoep--talon policies:
(NL amc Of CO.'tnaor) (IRRt3nc; compass)—pipi cbci (Y-.)In lion D1tc)
I
(Name Of ContTaaor) (lnsaranec CompanvJPo!ie-• Numb_r) (LaPir-,6on Date)
(Name of Connaaor) (LaRuanc-- Company/PoUcy Numbzr) (Expiraaoo Dau)
l
(Name of Contractor) ansuraac-z ComPZX,JPoUc), Numbs) (Et�ir�tion Date).
(aa .t�:c'od dcc.ilaccc+_}•w c�cuc�iafoca,�oc to.0 DLO Z)
i
I am'a sole-proprietor and bane no one woriz.ng for me.
( ) I am,a home o-,voer performing all the work myself.
NOTE:ply-•-be zwwr t4,,wJe bemw�vcra avbo c�ploy p�Day to ct7 t� -, c�eaoo a rcRU.ore on a d.•c11_�of
not a:ocs t1i n t'sv_twit,is t-b;eh the bomoo we rtsjdo«oo the p octn�,a,�purtea_s tbcro L c ox�—.ily x I d-ni to be
er,pioycs --the Aa(GL152=1(5)1 a.pptinaoa by a bcn m%-os fc a Gc=- or P=Mh r-y�+id the
less]r' of ea-=Ployer aadrr d.Wo,+.et CoasQoma,�oo/eL
[uoda:saod tbs a Dopy of tbi-mt®em may be rot---d-d to the Degar of or A,e&.o 'Oboe or[raur—ror tb-
°�'S= ciCc�tim and tlLt L-il=to a«aut:tovcrtcse uode Ic=oa 25 A of hIGL 15'2 ea Ir_d to the i=xssaim of eimiml pcasltio
eoaxi.ag o(a ftoc of up to andror impriwameot of Lo Doc ysar e.od a%il P=21-,,a is 6c form or.Stop W orti Ord.=a d.
Ciao of S 100.00 day LpdC:a
For dcp.rtaa u.e ooly
; Permit NUML--T —
`` mp.- L,ot
Sites of Li crrnZ ucc e -- J
w
M
1
Section 4. ZONING All Informatibli Must Be Completed.Permit Can Be Denied Due To Incomplete Information ft
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size r
Frontage j Vi +- I
Setbacks Front
Side L: '� )Z: 'L: R:=
a
Rear
Building Height -
Bldg.Square Footage
Open Space Footage % ;
(Lot area minus bldg&paved Mt -;�
parking)
--'�^ --
#of Parking Spaces I
Fill:
volume,&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 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' I and/or Document U
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained ® Date Issued:
C. Do any signs exist on the property? YES I NO
- IF YES, describe size,type and location: s,'
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location: B
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 , NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
*' City Of IVort'smpton
Buildigg Department
212 Main Street
Room 190
-587`124
Ni -M. 01060
pht3ne 1 Q Fad, 1 �-1 ��
APPLICATION TO CONSTkucT-,At R,REPAIRt`RE(nIOVAT 9 OW A O O TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION ,icc ^IOi
,,���-��, o Jae com�letted b�otfice
1.1 Property Address:
yx
ne O�erlaUistncf
�f
ElirSf%Distntt �.' r -0: CB Drs>trict '
SECTION 2-PROPERTY-OWNERSHIP/AUTHORIZED AGENT ,
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Zci
Name(Print) Current Mailing Address:
d-z-� g—zc 1— ()"6 (—e A) 6
Signature Telephone
SECTI -'ESTIMATED CONSTRUCTION COSTS'
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building l �-- (e)Building Permit Fee
2. Electrical (b).EstimatedTotal Cost of
�d D Construction from'6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) Check-Number
This Section For Official'Use Only
Building PermitNumber Dsued:
Signature: •
Building Commissioner/Inspector of Buildings- Date
kr HICKORY DR BP-2006-0437
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-021 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: ADDITION BUILDING PERMIT
Permit# BP-2006-0437
Project# JS-2006-0640
Est.Cost: $22500.00
Fee: $96.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: James Finn
Lot Size(sq. ft.): 16683.48 Owner: GALLUP SHIRLEY M
Zoning.URA Applicant: GALLUP SHIRLEY M
AT. 17 HICKORY DR
Applicant Address: Phone: Insurance:
17 HICKORY DR
FLORENCEMA01062 ISSUED ON.1012112005 0:00:00
TO PERFORM THE FOLLOWING WORK:Sunroom addition at rear of house
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 10/21/2005 0:00:00 $96.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo