23A-011 BP-2009-0491
S a: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0491
Project# JS-2009-000671
Est. cost $4000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Grouo: JAMES ROBERTS 117154
Lot Size(sq. ft.): 11020.68 Owner: ICRUMPHOLZ FRANCES V
Zoning:URB(l00)/ Applicant: JAMES ROBERTS
AT: 30 PARK ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
W ESTHAMPTONMA01027 ISSUED ON:11/5/2008 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 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# 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 11/5/2008 0:00:00 $35.003531
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
' I Department use only
City of Norhamoton Status or Permit:
Builriing Department Cum Cut(Dnvewey Permit
_212 Main Street Sewe-SeohcAvaiiabllty
_ - Room 100 Water/WellAvallabdrty
Ncchampton. MA, 01060 Two Sets of Structural Plans
pbo5e—58 7 1240 Fax 413-587-1272 Plot'Sde Plans
Nr� - IOther Speedy
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-$ITE INFORMATION
1.1 Property Address This section to be completed by office
q�� - Map Lot Unit
✓ _ ✓�// j % ElM S Overlay DisDistr
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT -I
2.1 Owner of Record: ,r ,10 //
..
Name(Print)
/ / // Mss: 1
Current ailing Addre
Telephone
Signaturd
2.2 Authorized A•ent
AV
Name(Finn / Current Mailing Address:
.�1� t ,, 4 „ 5,76-7-6 ,;.--
Signature Telephone
i
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be I OiaalUse Only
ww/. Dieted by oemit aoolicant
L Building 7G Y� I (a)Buiidmg Permit Fee
2. Electrical :J (b)Estimated Total Cost of
Construction from(6)
3 Punting Building Permit Fee
a4Mechanical(HVAC)
Pre Pr otecvon ,�/
E iota, = (1 :2+3-4 -5) I Check Number ,35 , I Y'• PC_
This Section For Official Use Only
Date
Buncmg Permit Numoer Issued:
I
Signature
. __. _S-_..—
Euldig Commissioner/Insperor or=mumps - fiat,
a
Section 4. ZONING Alt Information Must Ee Completed_Permit Can Be Denied Due To Incomplete Information •
Existing Proposed I Required by Zoning
This column to be filled io by
Building Deparvnent
I
Let Size I - _ __"_ ___ _ f
Frontage .. ..__.__
Setbacks Front I ---
I Side
Rear .1111
Building Height ---— —"' _-
Bldg Square Footage -__.._ I __ % I _..__,
Ogen Space Footage _ o I —
(Lorarea minus bide Sc paved ---
oarldnel
g of Parking Spaces 1 - .— I __— I
Fill:
(volume a Localism) — — — -
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW O YES O
IF YES, date issued:i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES O _
IF YES: enter Book Page and/or Document ft
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained Q , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q
IF YES, describe size, type and location:
E. WII the constuction activity disturb(dearnc.grading,
radiog
excavation, or filling)over 1 acre or s d part o;f Cali u.' Oar
tat will disturb over 1 acre? YES NO Q
IF YES,then a Northampton Storm)Water Management Permit from the DPW is required.
• �, SECTION_DESCR!FTION OF PROPOSED WORK;check all applicable)
New House ❑ I Addition TiI Replacement Windows I Alteratien(s) ❑ 1 Roofing -"'
I ,l Or Doors C 1
Accessory Bldg. Li Demolition ❑ j New Signs [0] Decks [I] Siding:C:11 Other[L^
Eref Deseicaon of Proposed ' /�
/
'cr, or.ex.s.rc bedroom Yes No Addirc new bedroom Yes No
Attached Ner alive P.enovavnc unfinished basement __Yes No
, Plans Attached Roil Sheet 1
I
15a If New house andor addition to existinahousina.comoletethefallowina:
a Use of building One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c !s there a garage attached?
d. Proposed Square footage of new construction_ Dimensions
e Numoer of arches?
Method of heating Fireplaces or Wcedstoves Number of each
c. Enemy Conservator Compliance. Messoheok Energy Compliance form attached?
h. Type of constru^on
Is occs:mcdon within 100 ft. of wetlands? Yes No. Is constructor within 100 yr. flccdpiain Yes No
Depth of casement or cellar floor below finished grade
k Will buldinc conform to the Euilding and Zonioe regulations? Yes No
I. Se^'c Tank _ City Sewer Phvate well City waterl
R Supply
SECTION Ta-OWNEER AUTHORIZATION-TO BECOMPLECEDCWHEN 7
OWNERS AGENT OR CONTRACTOAPP.IFC-'PCR UI
R BLDINW
GPERT 77
I I / -KA ,t-tZ ,Gf .as Owner of the subject
1 pmpE.^„ ,l� ,.#1-----)n a thorzo /11-1
-"KA-F-7 / _.-7211-1-1 ___. _
as on Ty behalf, it all ars�ative to work aut zed by this building permit applicator_
�2n iJn-7v1 %7 4- -6
Owner
I Signature of Owner - Date
L ✓Yc-1 / as OwrE hcr.
j Agent e c i c
e_. emer � n-'/ mA-Crrnat n on The foreccino -pplioation are tra and aacourate to the :est of my knowledge
I arc belief
Signer _rder the cairn arc peran of pe ur
nr iNNre '11+5__._027,„z”J`44J ' `/
eJ
I .
SECTION 8-CONSTRUCTION SERVICES •
a_ (sensed C- c^on Se a or t J No-A Picab e ❑
Name f Licenshid C - ‘-f
I L canse5efger
CPU/5
;across _ - I Expiravon ale
cnature y..7 Telephone
�. ‘1141"-e
t: -oistered-Ham ImnrovernertCmttra'ctor - - I Not Applicable
// / ❑
7 c
W , a - ' �
27(
lomcanv Name __ Registraho Number
duress Expiration Date
Telephone
�2 7-4,67-
ECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,§-25C(6))
'ohcers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit.
coed Affidavit Attached Yes...... ❑ No ❑
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.CMR 780. Sixth Edition Section 10935.1.
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 Otncial,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 ofEmpioyers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws.Annotated,NOV may be liable for person(s)
you hire to perform work for you under this permit.
The undersi ned"homeowner cerates 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
• - The Commonwealth of_ assachcsers
•
_ =_ - — Department of Industrial9 cc/dents
Li
_ = Office ofInvessi a ons
` = 600 14- shingion Street
- Boston,MA 02111
srnsw.mass.gor/dia
Workers'rs' Compensation Insurance Affidavit: BufdersiContractors.Electrician 5/Plumbers
Ac oiicant Information _ Please Print Lenibly
Yarn ci 3_saesstOrgan¢anon Individual 61/2./ ��"
_
,77-^ Z
"_
City'State"Zit): Phone-: .27— -#C.)J
Are you an employer?Check the appropriate box: Type of project(required): j
?.7 _Am= —elver with 71 am a general contactor and I i
% - have hired rhe rub-cone-actors 6- �'vew consaucCon
-employees (fig antilop pa=t-time]w
12.'I_am a sole proprietor or parmer- listed on the attached sheet. 7. IRemodeting
ship and have no employees These sub-contactors have S. 7j Demolition
I working for me de any capacity. employees and have workers' 9. ❑ Building addition
I.
[No workers' comp.insurance comp. msuance.-
re?:red-;
5. r l We are a corp oration and it 10.7 Electrical repairs or additions
15.7 I am a homeowner dace all work officers have exercised their 11. Plumbing repairs or additions
myself. [No
tat ofexemp¢on per MGL
[�- 2.7 Roofrey^a:s
insurance required.]T C. 152, §1(4),and we have no I
employees. [ho workers' 13.7 Other
cos.inanrance required] I
applicant
_. chocks box'] roast also 51113 out the sec.'.oa below showing nes workers'worker 'corpenszoon policy informa*.oc.
`:
. omeov.ces who scorns:tans afcavt:vdicaSg they are doing all work mid tat'hire outside connaors rust submit anew affidavit indicacnz such,
c'oncacrors that check dais box mus attached ar addition ai sheet show:no the nate of me sub.aneectors and sore whether or not those manes have
e-ruioy ems. If the sub-krontantors have etmiove .they must provide their workers'corapolicy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job sire
information.
Insurance Cornsa t Na..._:
Policy=or Self ms.Lick#: Expiration Date:
Job Sire Address: C_tv Smte,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 cirri-,al penalties of a
fine op to S1.500-00 arid;'or one-year imprisorrnent, 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 is smtement may be forwarded to the Office of
inv-esdsatiors of rhe DLA for insurance coverage verification
I do hereby ce.^.ifi'under the pains and penalties of perjury that the information provided above is ane and correct
,, ire' Date: /� - Q ryr
Phone
II1 ^^✓fjeciu!use z(y. Do not tyrue in this area,to be completed by city or town oijtcialfil
II City or To PermIILictiger
I} Issuing Authority(circle one):
1.Board of Health 2.Building Department ? CivITown Clerk lectrical Inspector 5. Plumbing Inspector II
IOther
6.
. Con: c: Pe.s.n:: Phone=:
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 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 ax 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 occupanev
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
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