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Cyril of NTGrifIa11133 foil
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a DEPARTMEI•IT OP BUIL.Dr,G I2qSPECrt01.'s -
j 212 Main Strect ' Municipal Building
Northampton, Hass. 01060
wORICER'S CONUENSATTON G`�SURANCE AF=, AA,
� (Ii cons..-rJ�*m1 tics)
'VI
tb a principal place of businessfresidence at: - -
(phone:')
(su-�_t/ci t•J lstatc�ri p)
do hereby certify, under the.p2in5 and penalties of per3ury, h:l
( ) I am an employer providing the follo.ving %vorkcr's comocnsation cove ale for my
emplovices wor�ong an ties job:
(I=s'u-mn=Conrad') (''r olio:NL-nbcr) (r;pir`tior. Dom}
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( ) 1 am a sole proprietor, general contractor or homeow-De*(a tie ore) znc have hired
the conu-actgrs lined below wbo hive the folio v-ing worker's c0Loen_1-2aon policies:
i
i
(i;am-, Oi Co t^CiOr) (I11Riralicc Co1ADan}'fpoUc Nru abc ) (E`:jil-duon Matt)
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(Name of Contractor) (L S-Wanec COm17anylpol.ie'i Ntrnc_r) (Lxpirz6on Date)
i
(Name of Coa-,MCtd,-) (Lusurane: Compan}•/pout}• Numlu) (Expim6on Dale)
(lame of Contractor) (Lnsuran ComraaylPolicy Numb r) ( xpiratioo Darr).
(ar..�L] �ocilC,if ace�a_�,-w induce iaforsa,.a oo p�ta,iaiag to.1J acct-_con) -
O I a.m-a sole proprietor and have no one worming for me.
( am..a home o.vner performing all the work myself.
NOTE=plesc be aware ti- .fie bemco.�ae a wto ecaploy Pe-."oaa eo da c+s^ c=z=,Oo c rcp2 r-ork oa a d,,,U;-,of
not Mott I a tam tmt.t is u1seh the bo=cowoc raid=a oo the vmunr6'7'Partc=•=tbeca ai ooc C==-_ny oeid.-od to be
eir♦�loy s a, A=(GLI152=1(5)).a,PpUci6 o by.bo=rn v=fc a lie:, oc panic=y c%-,de0x ti e
k-y I r-t-of=¢player undo dto W.,k e.Com�am..tion As:<
f uodess and ds+2 a copy oC tbix c==5 as=a y be for'vded to tho D,pP ms¢ AcdLe=e Office of lcs+r•nae roc%I-
�v�^e weireiioa and tti t f.:ilsa'e to s=ure'cOv—Cc U%3�C=voa 25 A cr MOL j32 can Icd to the ixpO oo of cimical pc-J6=
coca.:zi�of a fiat orup to S 1}oo.00.wor of up to co,-yr=r cod civil pcacttia is tSc form of.Stop Wort Ord-and.
C=of S 100.00 a day cpi=MG
For dc,�.r y��• u.c only -
Pcrmit Numb r
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' St�atltz-cofLic�.rs�JPcrmict�- �Ce �
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Gl ify of Narfhaillptan z
,yn H35Ath1lSttf4 �
DEPARTMENT OF BUILDD,,IG INSPECTIONS
INSPECTOR 212 Main Street • Municip d 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 1:is/her construction sups.:,Pssor. The state defines"Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a one or trvo
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 r'.egulations. 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 insuection (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 c4a D10,AY1.t4e project until h time as the proper permits and inspections are
made
/Yl rrj
I, /A 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 one
Date za D
Address of work q
location �J 32 j/��}�i/1✓J%/� d Y3/J
ew(Is errs
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SECTION 8-CONSTRUCTION SERVICES _t
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Sage sfece 'Norne'1rcm a�ieiren�Co t riE .- .; Not Applicable ❑
Comoany Name Registration um er -- --
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCt, F'11DAVkT(M.G:L.c.tm;,,§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...... ❑
. - t„
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 Iicense,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 1083.5.1.
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 buildine 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"cent. es and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State an Loca12`pning Laws 4nd S of Massachusetts General Laws Annotated.
j,
Homeowner Signature
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑:, Replacement Windows Alteration(s) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[0]
Brief Descrip' f Proposed _
Work: G�l1Ul/A%LNG 6AS'�10 e/J7" :1,- �/-/�� /`�Ga�� /� 77-1 C, S'%kCL l r
Alteration of existing bedroom Yes No Adding new bedroom Ye X No c�
Attached Narrative Renovating unfinished basement -Yes Yes No
Plans Attached Roll -Sheet
fray Ef'NeW-�iause��ld-viactdcttanktc�extnc�hotlslncl..camptete�,th;�atiow�ng: N
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 Numberof 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.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a,-OWNER AUTRORIZATION-10 BE COMPLETED WHEN
OWNERS AGENT OR CON T.RACTORAPPLIES FOR'BUILDING PERMIT
1, Ax/,) CI A f v as Owner of the subject
property
hereby authorize
to a o y be half,in aVeVslative to work authorized by this building perm i pplication.
2gna)Gre w r Date
Q Y\ as Owner/Authorized
Agent hereby declare that t1le statements and in ormation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed unde the pains d penalties of perjury.
oM /
Print me 1
/ � d Zd 0 �-
Signature f Ow /A nt D
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Section 4. ZONING Al I Informat-i6h 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
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bidg&paved
#of Parking Spaces
'
A. H 8 Permit/Variance/Finding e�b� �����s�
' �~� x~� �
NO D�7 �O� �� YES ��
IF YES, do5 issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0
IF YES: enter Book and/or Document#`
�� ��/��
B. Does the site contain ubrook, body of water orwet|ands NO K�J DON'T KNOW «_� YES
IF YES, has permit been or need to be obtained from the Conservation Commission?
' Needstnbeobtaimad v~-
\ ��ta�ned �=� Date �ssuo�'
^�� v�� ' �
C. Do any signs exist unthe property? YES K ) NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended Yo the property/ YES K ] mu
IF YES, describe size, type and location:
E. Will the construction activity disturb( hng.gradinq,tycavation,or filling)over 1 acre oriod part cfo common plan
that will disturb over 1acre? YESK ) r NO
_
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
w De on
City of Northampton
Building Department inrat '
212 Main Street e�rtre t
Room 100
Northampton; MA 01060 r Se s 5fy� rtraI?fat �
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phone 413-587-1240 Fax 413-587-1272 Fr�tkSltet , � '�
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1:-SITE INFORMATION
This section to be completed by'office
1.1 Property Address: r
Unit.
Zone O�rerlay Disfrrcf
#"z Er is ►ct i! CB t3� tncf
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZEDAGENT`
2.1 Owner of Record:
RiiJ iolve 6 SfA ,L P7171" oars
Na a(Print) Current Mailin ess:
- �arznce �'Y1 fI �/�to�-97g7
Telephongr
Sig /3
nature /7�- )
2.2 Auth oririizz�ed Agent: p /
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 oo�� ��, (a)Building Permit Fee
n'vCJ Q G
2. Electrical (b)Estimated Total Cost of
U Construction from 6
3. Plumbing Building;,Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) U U Check Number
This Section For Official Use Only
,Date
Building Permit Number. Issued:
Signature: r
i
Building Commissioner/Inspector of Buildings Date
File#BP-2006-0372
APPLICANT/CONTACT PERSON ROMAIN LIONEL G&MARY ANN
ADDRESS/PHONE 832 WESTHAMPTON RD FLORENCE (413)584-1286 Q
PROPERTY LOCATION 832 WESTHAMPTON RD
MAP 42 PARCEL 164 001 ZONE SR
ti
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: RENOVATE'BASEMENT&3RD FLR ATTIC SPACE(PLAYROOM)
New Construction
Non Structural interior renovations
Addition to Existing
Accesses Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
NI
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 Co 'ssion
/ 2Gd
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.
832 WESTHAMPTON RD BP-2006-0372
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:42- 164 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0372
Project# JS-2006-0543
Est. Cost: $3200.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): Owner: ROMAIN LIONEL G&MARY ANN
Zoning: SR Applicant: ROMAIN LIONEL G & MARY ANN
AT: 832 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
832 WESTHAMPTON RD (413) 584-1286 ()
FLORENCEMA01062 ISSUED ON:1012712005 0:00:00
TO PERFORM THE FOLLOWING WORK.-RENOVATE BASEMENT & 3RD FLR ATTIC
SPACE (PLAYROOM)
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 Occupant Signature:
FeeType: Date Paid: Amount:
Building 10/27/2005 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
832 WESTHAMPTON RD BP-2006-0372
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:42- 164 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0372
Project# JS-2006-0543
Est.Cost: $3200.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa. ft.): Owner: ROMAIN LIONEL G&MARY ANN
Zonin : SR Applicant: ROMAIN LIONEL G & MARY ANN
AT. 832 WES-I'HAMP ION RU
Applicant Address: Phone: Insurance:
832 WESTHAMPTON RD (413) 584-1286 O
FLORENCEMA01062 ISSUED ON:1012712005 0:00:00
TO PERFORM THE FOLLOWING WORK.-RENOVATE BASEMENT & 3RD FLR ATTIC
SPACE (PLAYROOM)
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: !o/li yam, House# Foundation:
A o S--b rev Driveway Final:
Final: Final: '
Rough Frame: G'(
Gas: Fire Department Fireplace/Chimney:
Rougll: Q_' !ns�.lation: 6)<
Final: Smoke: Final: (9 (- 61'-11-06 „
THIS PERMIT MAY BE REVOKED BY THE C Y OF NORTHAMPTON UPON VIOLAT19N OF
ANY OF ITS RULES AND REGUL ONS.
Certificate of Occu anc Signature:
FeeType• Date Paid: Amount:
Building 10/27/2005 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo