18C-148 (2) 162 PROSPECT AVE BP-2003-0927
GIS #: COMMONWEALTH OF MASSACHUSETTS
.Map Block: 18C- 147 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0927
Project# JS-2003-1486
Est. Cost: $1153.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DE Sheppard Roofing 105885
Lot Size(sq. ft.): 0.00 Owner: BARTON RUTH M
Zoning:URB Applicant: DE Sheppard Roofing
AT: 162 PROSPECT AVE
Applicant Address: Phone: Insurance:
224 BERKSHIRE TRAIL (413) 587-0092 ()
CUMMINGTONMA01026 ISSUED ON:4/29/03 0:00:00
TO PERFORM THE FOLLOWING WORK:SHINGLE ROOF OVER 1 LAYER
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: Receipt No: Date Paid: Check No: Amount:
Building 4/29/03 0:00:00 846 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
YY wow:t eg P.t2seiril"•
Cityof Northampton atuspfiPe
- Building Department Ye'r„ ita ; rZ. t .
212 Main Street Sewr�erSep lc A allabl ty4 it
Room 100 Water/welZa` i{y
APR 2 3 2003
Northampton, MA 01060 vie"�woP
Sets`ofStr c ur"aI FT?* iy
phone 413 587 1240 Fax 413 587 1272 ot/Site Plan '.a.ti••�a .k ` �= �"
Other Specify, •
:: 1.., � ' r •
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 bjje;completed by office
Map_ / fe--- Lot / Unit
G /O 6 d Zone Overlay Districts
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
4 /�e) ) rte., ,) /G 2 fLc5I /)c-g C/O
Print) I Trent Mailing Address:
( Telephone 2
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
�{ r3 �a�2__
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
cl
2. Electrical (b) F.stimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5) 115T, Check Number /f/6
.This Section For Official Use Only
Building Permit Number: 03— 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
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 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 0 Addition 0 Replacement Windows Alteration(s) 0 Roofing
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: )O1OvE, L Lip yap
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll ❑• Sheet O
kelftNEWMouse and a`d'dition,-fo ezisting housing,:completeitM follo�iving:
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. Mascheck Energy Compliance form attached? _
h. Type of construction
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
gr r±O
nn Y� , as Owner of the subject property
hereby authorize Om S) PZ,t9 111C e F/A- �'!'1. e to act on
my behalf, in all matters relative to work authorized by this building permit application.
y -227. )gC44. 2‘. /WA
'3fgnature of Owner Date
I, C , as Owner/ orized Agent
hereby eclare that the s ements and information on the foregoing application are true and accurate, to tTie-best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner
Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: s y�,,� Not
�rApppliiccable ❑
Name of License Holder : Oil,— SttiPMV C�v v 3 0 6
License Number
C-2-2(it 6 ii/lr fitIic h i/ ,n/C_ e 5-/i/U3
Address Expiration Date
404.1.41
Signature Telephone
is • -aki xlla4 11• m. ..r-men 7 1 "'_9 .: . ,;f ^ ,. Not Applicable 0
,P*, 'iii f2' - �acdPr' G �Nt, 1 r. ?Y�
Company Name Registration Number
q''SY. /3 Ktc- _sytim.__/m- 2/2Sc
Address Z. Expiration Date /
FAA+ Q
CC/1444l#A-6 ?/^ N'( d! Telephone 5- "”-ai 71-
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 k No 0
1 il, '',. 18 .a -1,: ®w"O r110- - t i e ' 0
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 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 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 _
•
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A ���ls"rfn6 f3tasancIiusrlla' " 1=
DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. O1(60 ''h�,
WORKER'S COMPENSATION I-NSURANCE AFFIDAVIT
I,
PA-/K __---
(liccnscdp, nlittcc)
with a principal place of business/residence at:
(splione
(strcct/city,s tdzip)
do hereby certify, and-er 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) (1 -pirt:tion Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following workers compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (L•xp it ue Date)
(Name of Contractor) (Insurance Comc :y/Polici Number) (l:x trztlon Date)
(Name of Contractor) (Insurance Conn;,anyiPol,c Number) (F.xi:ration Date)
(Name of Contractor) (Insurance Company/Policy Numlr_r) (Expiration Date)
(attach additional tract if:leC:nar::n ia!•Ae i n:orma:ion:pe tainirr,:.:al;oterma fir::•)
X I am a sole proprietor and have no one working ing for me.
( ) I am a home owner performing all the work- myself
NOTE:please Uc ahva:e that ts;.•iIc hccnco«ir_ra hriso ee.`eP I s to :vr.c:ancc artrt.:r_m cr t:,mir•t„tit mt.:��.t1h:;of
oY i crc;y to t
not incce th.a throe units in ta{id,the 1>v.:vatt- rai d�.,-s or ocr the r;.Ln.3 a,purter thereto a c not g-n's111v cot:tit:kr:d:o tc
cchploy -3 under the tvotkeel ceszwsatien Act(GLI52,:s 1(5)),r. li tie::by a hot:heouwtsrt for a Iiccntnc c pctn:i::::av c.^;n_' th';
legal status of an employer under the Worker's Compensation Acs
I understand that a copy of this statat:mt may be forw+vd«1 to the Department of Indsutrial Atti'un i OIGoo of lturarsoti for tho
j coverageverification ve i cation and that failure to mire coverage urd:.r section 25A of MOE.152 can lead to the imposition of crimi.:-1 per-shies
ooasutin of a floc or up to S 1.500.00 an dlor i tnprisooncn1 of up to cne year and civil pvulties in the form an Sir,,Wert Owes and a
fine of SI00.00 a day against ter
For dc{wtrneteal use only
y /i 1Number
� / C 5 Permit
Niapll Lot
Signature of Lice::;,e;lPcrmittcc r�
I
y:x;:..... - 1
r
Q-�HM 1P
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( ji$ 1j1 jiiassaclprsctts• _` _
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DEPARTMENT OF BUILDING INSPECTIONS _.i �=
INSPECTOR 212 Main Street • Municipal Building y •.
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 i.i;;'her construction sup '. Hsor. 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
I, 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