35-244 (4) City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work:
The debris will be transported by: �4.0 (Z"'s �t4
The debris will be received by: S'(414 l CCU 1 g(O'"Ict �--
Building permit number:
Nam of Permit cant
Date Si 7T.
Permit Applicant
f
City of Northampton
Massachusetts ys'• ; _ �f`
DEPARTMENT OF BUILDING INSPECTIONS ;
�$ 212 Main Street • Municipal Building
Northampton, MA 01060 rsw ,�t
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. 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 th 'r required inspections. Failure of the individual trades to secure
the permits and ins ect'ons as r ed c AY t project until such time as the proper permits
and inspections ar made
I, understand the above.
( o wner sident's signat requesti a emption)
I will ca the e all required buil g inspec o ecessary for the building permit issued to me.
Date �'1
Address of work to tion l
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d 1 Congress Street,Suite 100
Boston,MA 02114-2017
y•v www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information I Please Print Leizibly
Name (Business/Organization/Individual): _5414Aa4426 O g r 116
Address: 416 r kX
o(37a
City/State/Zip: ,? r hone#: ��2 — a 4�
Are you an employer? Check the appropriate box: Type of project(required):
1.® I am a employer with 4. ® I am a general contractor and I 6. ®New construction
employees(full and/or part-time).* have hired the sub-contractors
2.® 1 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 in any capacity. employees and have workers' 9. ®Building addition
[No workers' comp.insurance . insurance.
required.]
5. KcVomeapre a corporation and its MCI Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.®Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.®Roof repair
insurance required.] t c. 152, §1(4),and we have no 1
employees. [No workers' 13Other M `
comp. insurance required.]
*Any applicant that checks box#1 must also fill out 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$1,5Fa and/or one-year imprisonment, as well as ivil penalties in the form of a STOP WORK ORDER and a fine
of up to$250. ay against the violator. Be advise a copy of this statement may be forwarded to the Office of
Investigations th DIA for insurance coverage ve
I do hereby c rti under the pains d penaltie jury that the information provided a ove is tr a and correct.
Sign afore: Date: D
Phone#:
Offic' l use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Dame of Ucense Holder:
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Im rovement Contractor: / Not Applicable ❑
n v r o
Aid Comoany Name Re istration Number
Z;< 17�J4,60
Address Exp' ation Date
" e- �'� �a✓{ TelephoneZ�3
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 ermit.
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 10835.1.
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 under this permit.
The undersigned"homeow er"certifie �sumeWand onsibility for compliance with the State Building Code,City of 0 Northampton Ordinances S to and State of Massachusetts General Laws Annotated.
omeowner 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 [p] Decks LD Siding K3] Other(Ift
Brief De iptio of Proposed
Work: c a ev%lg4 G
Alteration of existing bedroom Yes No Adding new bedroom Yes N
Attached Narrative Renovating unfinished basement Yes 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.
1. 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
I, /Y v ,as Owner of the subject
property le
J a P
hereby authorize ��7 ► y I"'�
to i 00 on my b If, i 11 matters relative to work authorized by this building permit applicati n.
-2 -k I
Signature Owner' Date
c
r as Owner/Authorized
Agent he y declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signe , nd C he pain and p ies of p rju
Print NSm
Signature of ner/A nt 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
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ® DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 40 DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO 1&
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO 0
IF YES, describe size, type and location:
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 O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
,, City of Northampton Status of Permit:
Q 1� �k'! � g Department Curb,Cut/DrivewayPermit
LAM Main Street Sewer/Septic Availability
WX 3 0 2014 Room 100 Water/Well Availability
Nort mpton, MA 01060 Two Sets of Structural Plans
Electric. p;, ,-'jhone,413-58 -1240 Fax 413-587-1272 Plot/Site Plans
cns Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Proaertv Address
This section to be completed by office
z ' 4::: -J s j 11p ��(* �..U✓!e- Map Lot Unit
r1a ro e..*1 dVA Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
a 4 S i 0Ak .r 4
M int) Curre t Mailing AYdressl.
/? c -7?�
TerephUne
nature
2.2 Author
ized A ent:
C / Z ✓' Te
Name( rin Current Mailing Address:
13- d25 2.07
Signa re Telephone
S CTION 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)
3 2y� 00
5. Fire Protection _
6. Total=0 +2+3+4+5) ;3 OD Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2015-0134
APPLICANT/CONTACT PERSON INGARI MARY M
ADDRESS/PHONE 31 LADYSLIPPER LN FLORENCE (413)586-7704 Q
PROPERTY LOCATION 31 LADYSLIPPER LN
MAP 35 PARCEL 244 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out W4 It
Fee Paid
Tyneof Construction:_REPLACE SOLAR PANELS
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License 177503
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOIjMATION 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
n Delay
7—Z
Si ature o 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.
31 LADYSLIPPER LN BP-2015-0134
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-244 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: SOLAR PANELS BUILDING PERMIT
Permit# BP-2015-0134
Project# JS-2015-000239
Est. Cost: $3247.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SUNHAUS SOLAR LLC 177503
Lot Size(sq. ft.): 31145.40 Owner: INGARI MARY M
Zonin : Applicant: INGARI MARY M
AT. 31 LADYSLIPPER LN
Applicant Address: Phone: Insurance:
31 LADYSLIPPER LN (413) 586-7704 (�
FLORENCEMA01062 ISSUED ON.81412014 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE SOLAR PANELS
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 8/4/2014 0:00:00 $55.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner