42-142 (4) 1075 WESTHAMPTON RD BP-2017-0538
GIS COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 42- 142 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2017-0538
Project# JS-2017-000874
Est. Cost:$3200.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
use Group: Homeowner as Contractor
Lot Size(sq. ft.): 105850.80 Owner: NUTTELMAN ROBERT C
Zoning: Applicant: SIMMONS BLAKE E & LYN M NUTTELMAN
AT: 1075 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
1095 WESTHAMPTON RD (413) 586-6585 0
F LORENCEMA01062 ISSUED ON:10/19/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE RIGHT SIDE OF ROOF
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 ft 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:
FeeTvpe: Date Paid: Amount:
Building 10/19/2016 0:00:00 S40.00
212 Main Street. Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
!'�� r City of Northampton Status of Permit:
s/ QI .,t Building Department Curb Cut/Driveway Permit
�� . z 212 Main Street Sewer/Septic Availability
y aM Room 100 WaterMall Availab7l{ty
'e Northampton, MA 01060 Two Sets of Structural Plans
b`S c phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address' J This section to be completed by office
1075 westhifll/9Jz✓7 PLI Map Lot Unit
YI&7ence fl e/t4 at Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Owner of Record:
ilia Ke n Si'rnmtn i /975 ivesfham/ka id Alienee
Name(P p Current Mailing Address
L. AA-0 4 Telephone4jl.5 c
Signatur-
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 permit applicant u
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 gait 6. Total-(1 +2+3+4+5) 1360100 Check Number 'L%Jit �'7V
.,. This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Duiidings 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 From
Side L: R' L: R:
Rear
Building Height
Bldg_Square Footage
Open Space Footage
(Lot area minus bldg&paved
ze rkmg) ._..._
#of Parking Spaces
Fill:
(vo umc&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO GY DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO a' DONT KNOW 0 YES 0
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 a
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 V
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 0/
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing l
Or Doors Q
Accessory Bldg. El Demolition ❑ New Signs (tel Decks Ip Siding(D) Other[t
Bhef Description of Proposed //j /} 9�,L
Work: ,(s///itt EDD (� Rttri / S,de
Alteration of existing bedroom_ Yes ✓/ No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes .7 No
Plans Attached Roll -Sheet
Ba.If New house and or addition to existing housing, Complete the following:
a- Use of building:One Family W 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
a. 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 APPLIES FOR 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 Dale
11.1.101111.1.1.11....111111111111.1 .
, 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 (�
01,0
S:nature of Ow'er/,gent Date
SECTION 8 CONSTRUCTION SERVICES
BA Licensed Construction Supervisor: Not Applicable Ct
Name of License Holder':
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable 0
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,G.L,e.152,§25C(6)) 1
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....... 0 No ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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.CDR 780, Sixth Edition Section 108.33,1.
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 mere 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 Budding Official that he/she shall be
responsible for all such work performed under the bulldina 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"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 - 4,4 A
� � "'�
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: IU 7 6(/.Pf th I?( pl-i'y1 /2
d
The debris will be transported by: i40. �. rMin
VGI!
The debris will be received by: j/ �PC ///'ty(
Building permit number: J
Name of Permit Applicant type) 1, in VVI c* s
lD/i7/1 to Li ,"( n
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
DepartmentoflndustrialAccidents
)�
'l Office of Investigations
mii r sr
tmi: IS I Congress Street, Suite 100
"it lc Boston,MA 02114-2017
"'- t www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/OrganizatioMndividualy_
Address:
City/State/Zip:_ ___ Phone #: _ _ _ _ _
Are you an employer? Check the appropriate box: Type of project(required):
L C lam a employer with 4. 0 I aur a general contractor and I
employees (fill and/or part-time).* have hired the sub-contractors 6. New constmction
2.C I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have S. EL Demolition
working for me in any capacity. employees and have workers' 9. C Building addition
'No workers' comp.insurance comp. insurance.^
required.] 5. EL We are a corporation and its 10.0 Electrical repairs or additions
3 L.VJ! i am a homeowner doing all work officers have exercised their 11.[0 Pltmtbing repairs or additions
myself. [No workers' comp. tight of exemption per MGL 12.❑ Roof repairs
insurance required.] ' 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 worker compensation policy'mformanon
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tcontracto s that check this box must attached an additional sheet showing the name of the sub-contractors and stale whether or not those entities have
employees. If the subcontractors 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. if: 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 MOL c. 152 can lead to the imposition of criminal penalties of a
fine up to SI,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 5250.00 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 the poi and penalties of perjury that the information provided above is true and correct.
Signature: Date: /0/ / (Ci
Phone#: ill? .2202 023 50
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: __ —Permit/License a _ _
Issuing Authority(circle one):
I.Board of health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"._every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as "an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer_or the
receiver or trustee of an individual, partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, constmction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP) with no employees other than the
members or partners,are not required to carry workers' compensation insurance_ If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below, Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly, The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit icense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727.4900 ext 7406 or 1-877-MASSAFE
Fax # 617-727.7749
Revised 7-2013
www.mass.gov/dia
City of Northampton
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Massachusetts Cj.e.. -
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'i _ t DEPARTMENT OF BUILDING INSPECTIONS� 212 Main Street • Municipal Building Northampton, MA 01060
..-
:NS PECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNEREEXEMP1"IOli_A _ NOW .EsG_ ENT
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
foundationtf••ti1. •-f. e I . • . - • es.(before pour), a rough buildh g inspection
(before wpdtascpncealedl. in i• • •
, • if required) and a final buildinginspection
The building department requires these inspections before the work is concealed,failure to Secure
Yh€s€Inefi4.Gtion�" - ' .1. 'r . • .sir . . - r'. ' .. • r .. r ' ,r •..
impact
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, Lq✓1 S ri/ in en 9 understand the above.
(Malmo owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date k 'f`
Address of work location //75 pi/fifth th a JYIr�.J/7/f'1- a
. Fi tinct r try
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