23A-022 (6) 21 PARK ST BP-2003-1134
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A-022 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# E P-2003-1134
Project# JS-2003-1789
Est.Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 10802.88 Owner: PLATT CONSTANCE A
Zoning:URB Applicant: PLATT CONSTANCE A
AT: 21 PARK ST
Applicant Address: Phone: Insurance:
21 PARK ST (413) 586-3656 ()
FLORENCEMA11062 ISSUED ON:6/11/03 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL EXISTING WOODSTOVE
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: (9 k G —/2 -4 3 ..... ,'J
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. _.�..
anc .. i 4-- Si nature: ���
l ,ies. ,
Certificate of Occupancy
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 6/11/03 0:00:00 4394 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
T - ---1 , �Depattntuse'• Iy
'EN C p �( C`—j f Northampton Statusm
of Pertt �.
BUi d ng Department Curb Cut/Drweway 'er; 'it�� ' k'
21 Main Street Sev>rer/Septic A ailabtJ ty;:41` . .�
JUN 1 1 2003 i oom 100 Water/Well AyajJability .0
No-tha pton, MA 01060 Two Sets of,Structural ansIk
DEvrOFBult AMA 587.1240 Fax 413-587-1272 Plot/Site Plans` _i,
NO fl-IF:44716N,f"4 OUR i Other Specify
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:
v"f/ L����1` — Map Lot ci2ck Unit
Zoneya. ` " Overlay District
Elm St. District CR District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name:Print) Current Mailing Address:
CTelephone
Signature
2.2 Authorized Agent:
Name.Print) Current Mailing Address:
Signat.:re Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use Only
completed by permit applicant
1. B;:lding (a) Building Permit Fee
2 E = -!ca! (b) stimated Total Cost c`
Construction from (6)
3. P ,tubing Building Permit Fee
4. tv' cnanic.81 (HVAC)
5. Fi-e ?rotes tion
6. Total = (1 + 2 + 3 + 4 + 5) Check Number31,..37 +6—
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
•
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
t Size
Frontage
Setbacks Fro
Side L: t: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parkin)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) -
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
rief Description of Proposed Work: `s°p-a...d' Eyc,a.�J�bwif�r;-n-'f✓4`"'1�` ' -4 - -f,e r'm—
Alteration of existing bedroom Yes No 11 Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 • Sheet 0
6a. If New:h' iase°and'or`addition to existing housing, complete the followinj;
a. Use of bui ding : One Family Two Family Other
b. Number o' rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number o` stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck 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
I, , 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 Name
of Owner/Agent ( a 4¢--- �-—Signature ofDate Coif(/d 3
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : -
License Number
Address Expiration Date
Signature Telephone
rEiPill isfered Hb` mpro menfCont actor ' e mM-. Not Applicable ❑
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 0
11 -:Home-Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and o allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as s servisor. CMR 780 Sixth Edition Section 108.3.5.1.
De nition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is, • is intended to be, a one or two family dwelling,attached or detached structures accessory to such use and/or farm
stru tures. A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Suc "homeowner" shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
res l onsible for all such work •erformed under the buildin. t ermit.
As .cting Construction Supervisor your presence on the job site will be required from time to time, during and upon
co pletion of the work for which this permit is issued.
Als• be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Em,loyees 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.
Th:undersigned"homeowner" certifies and assumes responsibility for compliance with the State Building Code,City of
No •.mpton Ordinances, State and Local Zoning Law
s and State of Massachusetts General Laws Annotated.
o eowner Signature C. v"`}`t<e--"^'�
o�.�tvwr o
s� `�, (iiii) of Northampton
_ _ b
%-41 (f46 Aascarlfncrtta =5. T -
St• 441
DEPARTMENT OP DUILDlTIG INSPECTIONS
212 Main Street • Municipal Building f
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE A.FFTDAV1T
------------- --- ----------------(l i censerJpermittec)
with a principal place of business/residence at:
------ • •
(phone:;)
(strcet/ci ty/s tatcJb p)
co hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
- (Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
:attach additic ..I sheet if neccnIr:to iacluck im:anna:ioe pertaining to all cer -oecrs)
( ) I am a sole proprietor and have no one working for me.
( ) I ant a home Owner performing all the work myself.
NOTE:please be aware that while hccncows,who employ p=s m to(13 caint,,,oce,core.meieo Cr r;prit work on a d«tlliy of
not more than three units in which the homeowner read or at the grounds appurtenant thereto arc not generally ocraidcrt d:o be
employtn wader the worker's con-pc:saticn Act(GL1 S2,sa 1(5)),epplirtioo by a hom owm fora license cc permit nxy e. '-nee tbe
legal status of an employer under the Worker's Conspcnsation Act.
•
I understand that a copy of Chic ttatcasmi may be forwarded to the Department of to ,.drial AaiLent1 Ofrioo of haute oe for the
coverage verifscatioo and that failure to centre coverage,under section 25A of MOL 152 can lad to Cho imposition of criminal penalties
consisting of a fine of up to S 1500.00 and/cc imprisonmcat of up to one year and civil pcttaltia in the form of a Stop Work Order and a
firm 0(5100.00 a day against me.
Foe dcputrnaital u.o only•
Permit Number
suing;) Lot
Signature of Li _ thLe
ccnsccll'ernuttcc
o gHAMpz. —
��,,Ai 4-4 ixt of Northampton 17 _*=�
�� '� � fTassacltusctts _ - 1_
Qf ti �•
'�'� DEPARTMENT OF BUILDING INSPECTIONS ', `•,e f
INSPECTOR 212 Main Street • Municipal •Building •:`
Northampton, MA 01060 •
r
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 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 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 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
d (� 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