35-247 ' 4
The proposed studio building at 19 Ladyslipper Ln, Florence , will not be used as an accessory
apartment. The building has no water facilities, and it's sole function will be a work space.
Thanks
Mark Meunier
19 Ladyslipper Ln
Florence, ma 01062
5869753
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MAR 2 8 2003
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR
212 Main S�;,ct i�= Nlmucilril Buildin
Northampton, MA 01060
IV
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as !Js/her construction sups_: ,- sor. The stage defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or thvo family
divelling, 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
4
I, 1 Jl o(L(/C W e -rj eL,-- 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 3 - 1
Address of work L
location (�1 LoU)y (-C,pP`e,,— '�'
Ntvxr� — _--
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b (lLitll f �;�a rf llaillflftill ( �
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DEPARTMENT OF BUILDING INSPE'CT'IONS
212 Main Street ' Municipal Ek-nlclinh
Northampton, Afass. 0140
WORTQ�R'S COMPENSATION 1NSURANCI' AFFIDAVIT
(]i�nscci��;tn;itcc)
wah a principal place- of buslesdresidence ar
(phone:'}
do hereby cer�i y, Under Cho PAS and poncho of PxM PHY, tha
I wrl an empioyer providing the Mo•>ann v.or cKs comnens Iron cove.rti e for 1ny
employees worh-ing on t'lis job.
(hourinco Comywy) --- -:c c,Nuaibcr) -- - - (Expir.tor.Datc) -
( ) I art a sole proprietor, general co'ntracto- ;"r honleov"rncr (circle one) anti have flifed
the contyactors hsted be1Ov-,, vi'l10 have [ire %VoFkee js CO( p 1152't1on. pCliC'm
-- (NI'mic of COI1tmctor) (iI1SL'i' C:, t_,01:' -;'�:�1'oI1C'j ��l.Ill���;) _-- lI.?'•::+.LOi. Date)-
(Nwnc of C,onymol (n15UL:Iw W _ ..Qok. ' -i0, bate)
f , -)
�3mC of C6I111?Ctol) (II1SZ1raP.0 �,Oi::�: i'ilt?(��iCT 1vnlrl Y�r) + - , + -: I-'IItt'
(Name of Conusuclr) (ItlszIranc Com..n_I-,•,,Pokey Numb--r) (F?: ir.:;io: Date)
(M"dt WItimal sma
( I and it SoiC llroptlC Oi iir1Q have no one �,"I f lli for i]1C_
) t?iI1 <? 11O111e ow!1 I'C1fe-ID1I1: ill iI]: V,�,`i:, ii]VSClt
NOTE' Ac-ac Lac-ware that.Ni ilc
not uKrc 1:2-11 tluco units in"on"a}rxx—s oc a:t` .�.�:._c��z�•.urtc. r'L`cRc uc o-�((vrsallV o;r.::::r ::�
legal"am;of an om>loyoc uodcr tf.o Wuiccet Coca;x ration/cL
I undo tt+n l tliil a copy of the cintca mt cnxy bo fo x+v tod to t r[Y.Sxi tn7 of of Ina u rial A it nt� (fiico of I: ur n=o for U.
coverige vaifieatioc and tlLt failure to t.nue coverng--ur r zceU, 15A eI MOL 152 can lend to the innposifion of r 1 pa 5lt:es
co ti_tting of a fm,of up to S1,500.00-r.x imprison-11.-:1 of up t)cr-.}`ar naj civil pc a16c3 in d<fo n of n Stcp\Vc 0�1�v:d a
f of SI00.0t1 a city Irr.ix-t rnr.
roc cSq;u Lix7tal uic only' ��
Pcrmtt Ntuntr:r
-
Sit;nature c�ti tc�n•,cJPcrmtttr: --- -
SECTION:$; CONSTRUCTION:SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
r
Address Expiration Date
Signature Telephone
f Witi��a i � „ Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION;IU 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...... ❑
O� wane gem �4 n�
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 fo-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
SECTIONS «DESCRIPTIONOF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. )9. Demolition❑ New Signs [ ] Decks [ ] Siding[ ) Other [ ]
Brief Description of Proposed Work: /1%1' 1`t T i U 01 0
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll❑ - Sheet 0
sa 1fNew ho"use ' dor ac!'dition toexsting=iFio`u`sing _conpletthe=ffol'lowing
a. Use of building : One Family Two Family Other X1
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. Mascheck 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
OWN
EFtS,AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
e ° 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
Signature of�Agent Date
3
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Fronta e �d 1440
Setbacks Front /CO
Side L: R: L: 6p O R:i !�
Rear
Building Height c,
Bldg. Square Footage j % Z�
Open Space Footage ,,,�� ��!!
(Lot area minus bldg&paved ;b;o
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
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 NO
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:
'-�Cityr:Of`Northampton tus P
a �B,�,ilding Department
- 212 Main Street Se er .e, lc 1
Room 100 a erlWe v
-Qrthampton, MA 01060
phone 413.587.1240 Fax 413.587.1272 it an
Other}Speal�. �°q,,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property This-sectionto be completed by office
P3W €
�
'a!�' 1 /�(�( `/ ✓— M! r1 Map . / lot Ovi�
_�� FJnit
Fk.o v ej%c M 4S 5 C)I Zone Overlay Distnct
Elm St, District CB D�stY,�ct
SECTION 2 - PROPERTY OWNERS HIP/AUTHORIZED'AGENT
2,1 Owner of Record:
PAIR—
Name(Print) Current Mailing Address:
Telephone
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. Elecirical (b) Estimated Total Cost of
Construction from 6
3. Plumbing ____ (�Y—W Building Permit Fee
4. Mechanical (HVAC) l Z ct c7
5. Fire Protection
6. Total =(1 + 2 + 3 + 4 + 5) (3 .'j L> Check Number l
This Section For Official Use Only
Building Permit Number Date Issued:
Signature;.
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0769
APPLICANT/CONTACT PERSON MEUNIER MARK
ADDRESS/PHONE 19 LADYSLIPPER LANE (413)586-9753 Q
PROPERTY LOCATION 19 LADYSLIPPER LANE
MAP 35 PARCEL 247 001 ZONE SR
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: CONSTRUCT 16 X20 ARTIST STUDIO
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildinp,Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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 ssion
` a
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.
BP-2003-0769
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Build ft
Category: shed BUILDING PERMIT
Permit# BP-2003-0769
Project# IS-2003-1265
Est.Cost: $13950.00
Fee: $32.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.1): 51836.40 Owner: MEUNIER MARK
Zoning: SR Applicant: MEUNIER MARK
AT. 19 LADYSLIPPER LANE
Applicant Address: Phone: Insurance:
19 LADYSLIPPER LANE (413) 586-9753 Q
FLORENCEMA011062 ISSUED ON:411103 0.00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 16 X20 ARTIST STUDIO
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: Receipt No: Date Paid: Check No: Amount:
Building 4/1/03 0:00:00 1908 $32.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo