23A-129 (2) a
City of Northampton 212 Main Street, Northampton, MA 01 060
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:
The debris will be received by:
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
,--__ City of Northampton
Massachusetts 4S�s sGf1
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 rs�w•5�1�ti
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 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 Industrial Accidents
Office of Investigations
_ 600 Washington Street
Boston, MA 02111
' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: 32 .5 C
City/State/Zip: — C.&-'-("'f-4"t -f— !tAl Phone #: 5_30 6 c� Z
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. E] I am a general contractor and I 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
2 X I am a sole proprietor or partner- listed on the attached sheet. 7.` Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. employees and have workers' 9 Building addition
[No workers' comp. insurance comp. insurance.1
required.] 5. � We are a corporation and its 10.E] Electrical repairs or additions
3.❑ 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 repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners 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: A `^
V
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address:
WD City/State/Zip:-F Lar-M D
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
Investigations of the DIA for insurance coverage verification.
I do hereby certify under thepayny and penalties of perjury that the information provided above is true and correct.
Si mature. Date: J
Phone#
Official 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 £
Name of License Holder: i
License Number
Address N Expiration Date
Signatu a Telephone
9.`Registered Home Improvement Contractor Not Applicable E.
Company Name -{- Registration Number
Address / i Expiration Date /
3-L '-� �T ���b� Telephone TJ t�
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. -.Hame Owner:Exemption.
The current exemption for"homeowners"was extended to include Owner-occu led a in s of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not p ss a license,provided that the owner acts
as supervisor.CMR 780. Sixth Edition Section 108.3.5.1.
De im ion rson(s)who own a parcel of land hich he/she resides or intends to reside,on which there
is,or is intended to be,a one or two welling,attach or detached structures accessory to such use and/or farm
structures.A person who constructs more tha e e in a two ear period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building O cia, ,a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed u er the buildi ermit.
As acting Construction Supervisor you resence on the job site vNLbe required from time to time,during and upon
completion of the work for which th' ermit is issued.
Also be advised that with refere to Chapter 152(Workers' Compens>an r 153 (Liability of Employers to
Emplo yees for injuries not re ulting in Death)of the Massachusetts Gented,you may be liable for person(s)
you hire to perform wo for you under this permit.
The undersigned"ho eowner"gcrtifies and- - he State Building Code,City of
Northampton OrdinkmMS fate and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature.
f
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 [❑] Decks [❑ Siding[❑] Other([2]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. if New house and or`adtlition te e followinc:to
a. Use of building :One Family Two Family Other
b. Number of rooms in each family unit: Number of B rooms
c. Is there a garage attached?
d. Proposed Square foota of new construction. Dimensions
e. Number of stories?
Fireplaces or Woodstoves Number of each
f. Method of heating?
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 . of wetlands? Yes No. s construction within 100 yr. floodplain Yes No
j. Depth of basemen cellar floor below
k. Will buildin nform a Building and Zoning regulations? es No .
I. Septi an City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
propert
hereby authorize c�L�1
to act on my behalf, in all matters relative 0 work authorized by this building permit application.
Signature of Owner Date
Fn
V , as Owner/Authorized
Agent hereby declare that t e 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.
Z lr- Z7 C`
Print Name .i
Date
natu ner/Agent
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
F,'6,Qtage
Setba s Front
t
'de
L:= R:= L: R:=
R ea,
Building Height
Bldg.Square Footage %
Open Space Footage % I
(Lot area minus bldg&payed
parking)
of Parking Spaces
Fill:
(volume&Location
A. Has a Special Permit/Variance/Fi ndi ever been issued for/on the site?
NO 0 DON7 KNOW YES 0
IF YES, date issued:'
IF YES: Was the permit recorded a the Regist f Deeds?
NO (D DON7 K OW 0 YES 0
7
IF YES: enter Book Pag and/or Document#E
B. Does the site contain a broo body of water or wetlands? 00 DON7 KNOW (DYES C)
IF YES, has a permit b n or need to be obtained from the Cc ervation Commission?
Needs to be obtaine 0 0 Obtained Issued: i
C. Do any signs exist the property? YES 0 NO 0
IF YES, describ size, type and location:
D. Are there any roposed changes to or additions of signs intended for the property YES 0 NO 0
IF YES, de tribe size, type and location:
E. Will the cc truction activity disturb(clearin'9ing.'excavation,or filling)over I acre or is it part of a common plan
that will di turb over I acre? YES NO (D
IF YES, t n a North on Storm Water Management Permit from the DPW is required.
t t Qepartment use only ,.
of Northampton Sta#us of Permtt
ding Department CtrrB Cut�Drlyeway Pelmt#
L I MAY
5 2015 j 12 Main Street :sewer/sep�ICAua�rabl►rty "
^y F.
Room 100
Electric, P L mMomq&G-----I Mort ampton, MA 01060 ,Two refs of 5#ructrirat Ptarfs
mib�(f+l��n 7-1240 Fax 413-587-1272 PIoflSite Plans
:Other 5pemfy
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 Umt -
����"���� V" ��"r� ElmSt_Distnct CBDlstnct
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Jac &V\ 46 o ltto L-F-- 5t- ice`-&o LJQ
Name(Print) Current Mailing Address:
J . S f-e^.tr Telephone _s-I ffL
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
!.
�p 6
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
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: —
Building Commissioner/Inspector'of Buildings Date
File#BP-2015-1067
APPLICANT/CONTACT PERSON JEFFREY BOTT
ADDRESS/PHONE 32 Pine Street FLORENCE01062(413)530-6920 Q
PROPERTY LOCATION 46 MIDDLE ST
MAP 23A PARCEL 129 001 ZONE URB000)/
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: REMOVE NON-BEARING WALL AND ENLARGE CLOSET DOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildine Plans Included:
Owner/Statement or License 053157
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 e y
Signature of Buil mg 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.
46 MIDDLE ST BP-2015-1067
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A- 129 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2015-1067
Project# JS-2015-002019
Est. Cost: $900.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JEFFREY BOTT 053157
Lot Size(sq. ft.): 19602.00 Owner: WALMSLEY CATHERINE A
Zoning: URB(100)/ Applicant: JEFFREY BOTT
AT. 46 MIDDLE ST
Applicant Address: Phone: Insurance:
32 Pine Street (413) 530-6920 () Workers Compensation
FLORENCEMA01062 ISSUED ON.51712015 0:00:00
TO PERFORM THE FOLLOWING WORK.REMOVE NON-BEARING WALL AND ENLARGE
CLOSET DOOR
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 Deuartment 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 5/7/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240, Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner