43-153 (2) 17 HAWTHORNE TER BP-2016-1212
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block:43 - 153 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-2016-1212
Project# JS-2016-002085
Est. Cost: $10000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 43995.60 Owner: JANKOWSKE MARK
Zoninp-: Applicant: JANKOWSKE MARK
AT: 17 HAWTHORNE TER
Applicant Address: Phone: Insurance:
17 HAWTHORNE TERR (540) 239-7168 O
FLORENCEMA01062 ISSUED ON:4/19/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL MASTER BATH
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 4/19/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
„ - Department use only
City of Northampton Status ofParmrt
APR 5 2016 X11 �II� t
Building Department Curb Guf/Dri+[e�tvay Perml#
212 Main Street Sewerts
eptic,4uaifa6lfrty
Room 100 UVaterfUlfe7�Rvatla6111tj ' FE-Hs.
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Northampton, MA 01060 Twq,SefsafS#ructgrai Pia s
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phone 413-587-1240 Fax 413-587-1272 PIof/Slte PlanaUa :� �-_-,= =
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
LL:=. This section to be completed by office =
1.1 Property Address: = z:
err, --- — _4_
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Zne Overlay DisfrIcf s
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_Elm StDistneY
. SECTION 2.=PROPERTY OWNERSHIP/AUTHORIZED.AGENT'
2.1 Owner of Record:10L
>- K&_&_ wL<o t-PSke 1-7 ler,- F(oru,,t_ 0/df Z
Name(Print) Current Mailing Address:
Telephone
Signature 7
2.2 Authorize Agent:
Name(Print) Current Mailing Address:
Signature Telephone
.SECTION 3 -ESTIMATED CONSTRUCTION COSTS. .
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building --f, $Oo (a) Building'P.ermit Fee
2. Electrical �1 , (b) Estimated Total Cost of
Construction from' fi `:
3. Plumbing �L �O a Building Permit Fee
4. Mechanical(HVAC) Jr'
COO
5. Fire Protection
6. Total=(1 +2+3+4+5) /D OC DOO Check Number
This Section For Official Use Oni
Date
Building Permit Numb Issued:
Signature
Buiiding Commissioiler/In,spector of Buildings: Date
~� "
�
"
Section 4. ZONING AR 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
Rear
Building Height
Bldg.Square Footage %
Open Space Footage
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Hasa Special Perm djVariance/Rnding ever been issued for/on the site?
�~� �~���
NO �,x��y DONTKNOY� �~� YES
IF YES, date issuedJ
IF YES: Was the permit recorded atthe Registry ofDeeds? /
NO � Y DONTKNOY/ YES
��
IF YES: enter Book Pag and/or Document#
B. Does the si ��site NO �~� DONTKNOW �~��/ YES ����
� �
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs to be obtained y~� Obtained �~� Date
\_y �~� '
C. Doany signs exist onthe pnoperty �� ��� YES �~� NO �,�
IF YES, describe size, typeand location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excavation, orfi||ing)over I acre oriaitpart ofacommon plan
�hotv�/|dis�ud�over1aoe? YES ���� NO �^~��
'
IF YES,then oNorthampton Storm Water Managen�entPermit from the DPW isrequired. �
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aoolicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors 1
Accessory Bldg. ❑ Demolition '� New Signs [O] Decks Siding [D] Other[71]
Brief Description of Proposed f e r.O 4 / 1*4 �/
Work: G�•l !i1
Alteration of existing bedroom Yes '-"'No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
_ 777 --- -..:
sa. If New house and or addr ma.. G'exis mg-. ousinct, cor»o(ete: foGo Ufi c€_
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.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION.TO BE COMPLETED .WHEN
OWNERS AGENT OR CONTRACTOR APPLIESTOR.BUILDING PERMIT
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
Aox 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 Owner/Agent Date
I
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
-- — – T7 - Not Applicable £
9 .Registered.Homelmprovement.Cont�actor PP
Company Name Registration Number
Address Expiration Date
Telephone
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 Ho:meowner Ege� ption
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 shaU not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Oficial,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 pen-nit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,St Local oning Law and State of Massachusetts General Laws Annotated.
Homeowner Signature..
i
. The Commonwealth oflMdassachusetts
Department of Industrial Accidents
i- -
Office of Investigations
600 Washington,Street
r.
Boston,MA 02111
www.rnass.gov/d$a
Workers' Compensation Insurance Affidavit: Bu Eders/Contractors/Electricians/Plunsbers
Applicant Information �/� Please Print Legibly
f
Name (Business/Organization/Individual): • lP� J �t-K h0 W flee-
Address: (� � w`�aU-nQ �el''/'+�Ge-
City/State/Zip: a-P-eAc t, JAA- d (OG 2-Phone#: 5Y0 _ 2-3T_ ? 14e
Are you an employer? Check the appropriate box: Type of project(required):
. am a general contractor and I
1.❑ I am a employer with 4 ❑ I � 6. F-1 New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ 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 mein any capacity. employees and have workers' y ❑Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We area corporation and its 10.0 Electrical repairs or additions
3.E?' am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
Tmyself. [No workers' comp. right of exemption per MGL 12.E] 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:
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 $1,500.00 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, o hereby certify under the pains and enn' ofperjury that the information provided ahho`ve is true and correct.
Sip-nature: Date:
Phone#: �YO o2 ,) — 7 t4
Official use only. Do not write in this area, to he 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#:
City of Northampton
Massachusetts .s,.• 4 aJr.,
CCC c�7
DEPARMXXT OF BUILDSNG INSPECTIONS '
212 Main Streets Municipal Building
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HONM 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 buildinq 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 l
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
E d inspections are made
J�x.n Ka�„aSKe understand the above.
(Home owner/resident's signature requesting exemption)
will call to schedule all required building inspections necessary for the building permit issued to me.
)ate
address of work location I+CwIVt Gee 1 e3`t*c-f
-( -extC )A 006 2
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40; 554, 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 15OA.
Address of the work: HOAO-K•1*, W 0(06 '2
The debris will be transported by: i�a Sec.. `�c� Tn-c.�-�k�
The debris will be received by:
Building permit number.-
Name of Permit Applicant m rr
ell rsll6
Date Sign lure of Permit Applicant