43-078 (3) BP-2009-0254
GIS#: COMMONWEALTH OF MASSACHUSETTS
MfraiiiidOrinft'T 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-2009-0254
Project# JS-2009-000334
Est.Cost:$1000.00
Fee: S35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
use Group: Homeowner as Contractor
Lot Size(sq.ft.): 15638.04 Owner: MCQUILLAN DONALD&VALERIE
Zoning: SR Applicant: MCQUILLAN DONALD & VALERIE
AT: 49 DUNPHY DR
Applicant Address: Phone: Insurance:
49 DUNPHY DR (413) 527-7343 O
FLORENCEMA01062 ISSUED ON:9/8/2008 0:00:00
TO PERFORM THE FOLLOWING WORK:REROOF
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 9/8/2008 0:00:00 $35.00368
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
Q A�. Department use one
City of Northampton status,ot Penn1t, i^
Betiding Department Club Cut/Driveway Permit
T / O'S 212 Main Street SBwedSepticAvatiabiiity
% Roam 100 Water/Well Availability
SEQ
Niiitka_mpii, MA 01060 Two Se1inttnictural Plans
phone 413-581-1240 Fax 413-587-1272 Plat/Site Plans
Otherapeafy"
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
QUnPt y Map Lot Unit
/
Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENTE��))
2-t Owner of Record: ifg// A(triC- ' (' t-CC-3vt, {yy
(4.,
k
DM-1/4' ren M• Kt( Qui 1I An 41 Orli • 11 I
Name(Print) Current Mailing Address: yy 3 - 5 2 7 •-7 3 LT. .3
Telephone
Ognature
2.2 Authorized Agent
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Defiers)to be Official Use Only
completed by permit applicant
1. Building •,�...- 'f 00 Ui (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5 Are Protection / /
6. Total=(1 +2+3+4+5) Check Number ,3.pg y/`3y7
This Section For Official Use Only
Building Permit Number: Date
issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING Alt 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
Side L:. R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill: _._...
(volume&Location) - - --A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
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 O DONT KNOW O YES O
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 O
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 O
IF YES, describe size, type and tocation:
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 O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTIONS.DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) 0 Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs kJ) Decks (M Siding E:11 Other la
r,rkLAtietlescription of Proposed atatT
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 end or addition to existing housing,complete the following:
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
In. 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
t,^ .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
I, ,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 Namep I
�L / `V ((/1 �•1s• c9k1C� —OS;
Signature of Owner/Agent Oats
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
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.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 0 No ❑
11. — Home Owner Exemption
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 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"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and Sta of Massachusetts General LawsAnnotated.
1 kitHomeowner Signature v 'M( V\ RA t,,
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1^ The Commonwealth of MassachusettsDepartment of Industrial Accidents
Office of Investigations
. 600 Washington Street
Boston,MLA 02111
www-mass.gov/dia
Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly•
Name(Business/Organization/Individual): (j[( I t rill I 1 v�q I t C;r( � t i( Ir
Address: 171 D el 2
City/State/Zip: Rue gen Phone#: 4( t 3 S 2 7 ^7 t43
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-tine).' have hired the sub-contractors 6. ❑New construction
2.0 I am a sole proprietor or partner- listed on the attached sheer 7. ❑Remodeling
ship and have no employees These sub-contractors have S. Q Demolition
working for me in any capacity. employees and have workers' y Building addition
[No workers' comp. insurance comp. insurance.]
xrquired] 5. (D We are a corporation and its 10.0 Electrical repairs or additions
Wif am a homeowner doing all work officers have exercised their 1 i.❑Plumbing repairs or additions
[No workers'' cota right of exemption per MGL
p 12.D Roof repairs
insurance required.]' c. 152, I(4),and we have no
employees.[No workers' 13.0 Other
comp. insurance required.]
`Any applicant that checks box trI must also tat om the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors most mbmit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the cane of the subontrnctors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'con,.policy number.
I ant an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy ti or Self-ins.Lick': Expiration Dam
Iob 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 a 152 can lead to the imposition of criminal penalties ofa
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 3250.00 a day against the violator. Be advised that a copy of this statement may he forwarded to the Office of
Investigations of the DR for insurance coverage verification.
I do hereby cerrisry under the pains and pedes of perjury that the information provided above is true and correct.
,{ t r 7 �"S -O - C
Sigvanre: l jCtkh.r ,, ^� `l Ut his Date:of cr
Phone#;: "a 2. 7 - 1...... 4 3
Official use only. Do not write in this area,to be completed by ray-or town official
City or Town: Permit/License#
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#:
•
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 railed to
inspect work at various stages, which include foundation/footings (before backFh1111-
sonotube holes (before pour). a rough building inspection (before work is
concealed), insulation inspection (ifceguired) apd a final building inspection. The
building department,requues 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 11 // /1 in1 XAc rr77
� 1� — undersand 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 0 - US _ cy
Address of work
location 4 C1
�1 � C el _