18C-148 (3) 162 PROSPECT AVE BP-2003-0928
GIS##: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C- 148 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0928
Project# JS-2003-1487
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: WALDRON GRACE E&ANN G WALDRO
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
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C-,ity of Northampton StatuspftPermit. ,,, �, .�} r
Building Department C bi Cut%D ve''a •e. ttf4 :'t" ,r '.
' ' t .c TMF i fi r S -w. r '-,,. 1
•212 Main Street Sew r>/S is A arla.f ty _ � . ..
Room 100 a er •i I'va a rl i Ii1'4 ;.4itetvr . yl'A4,5:"! , `,:
4.`1ty..
APR2 3 2003 Northampton, MA 01060 ,DSet 'oftStr ;aura`P a . ,H:mot`• i '
phoner =. . 'o .1 s-.4L.y M��
413.587.1240 Fax 413.587.1272 Plot/S!te}P.1a sa���.,a�.,31.
t Other Spec t . x�... ; .
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
b�� PQi C /�e Cttitr Map / � Lot J l <J Unit —
4/C 6 v Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT — —
2.1''Owneer of Record: �i�
r'- - — -(-3 --- _----
Name(Prin ' C nt Mailing Address:
---- — Telephone 7
Signature V 3 37
1
2.2 Authorized Agent: .
S itiPfJ' W ZZ 41 032ltf1/4_,5/i`12, • .rie-1f1L
Name(Print) Current Mailing Address:
5177—c,v92.
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
1151
2. Elecuical (b) I 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) 1 I 3 Check Number f! l i o __
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date ___
f
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 arca 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
I F-YES, describe size, type and location:
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House 0 Addition 0 Replacement Windows Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signsj Decks [ ] Siding[ ] Other [
Brief Description of Proposed Work: 5(f(t✓ Cov6 G1 yo tor- Cy -
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative O Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet U
6a.If?Nei house aTtdladdition'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. 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 fi '. Sf}l`'P19)2p coAt.74tc-i L _to ac; or
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
, as Owner/. lorized Ag
hereby declare that the sta e ents and information on the foregoing application are true and accurate, to the o my
knowledge and belief.
Signed under the pains and penalties of perjury.
DThv 5flFpth )
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1
Jeri- — -11/ 3
Owne Agents Data
SECTION 8-CONSTRUCTION SERVICES
r 8.1 Licensed Construction Supervisor:s Not Applicable 0
Name of License Holder : p /ti1> e O e 6 6 306
License Number
sEy fAle-Sft/ie4 7 r(L ( - v ,n , /44p 5-/16 o3
Address O/ Expiration Date
57-00 7 2-
Sig ure Telephone
i9`fRegiste'red H mo e�lrripr`gvem`enf Contractors �'; z Y. , tt' 3,.x, ?, Not Applicable 0
, 91- pimp (Zd o 1liA6 nT 1- _ _ 103`Sg`S—
Company Name Registration Number
22L( Q S it-nt ?' 2&177 7 1 z.l7a
Address /� c� Expiration Da e
COMM //u(, �^1 Mf 1. 0/0 Z( Telephone 5 ` / Z�
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 No 0
-.: r `omex ~ wne , ttnp. '0 1
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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0.1411) 7 c Nartlitiml)folt-
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""••••••,cs, IMPAliTMENT OF BUILDING INSPEGFIONS
212 Main Street Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(li=nscciperritittee)
with a principal place of business/residence at:
. ________
. . .
(strect/cityls-tate.iiip)
do hereby certify, tit,: pains and penalties of perjuty, that
( ) I am an entpioyc: providing the followine %votker's compe.nsanon cove: 1.01"
employees working on this job-
_ ------- ••-• ---------
(lasuxancz Company) (Pciicy Number) (1-;_x-nimtfn Date)
( ) I ant a sole proprietor, general contractor or homeowner (cirde one) .wc.:. liave hired
the contractors listed below who have the foilowing worker's cotapensation
(Name of Contmczc ilusumncc.Company/Policy Numbet)
(Name of Contraczc.r1 insuranco Com-a-tv/Potc• Number )ate)
(Name of Contractor) ([nsuranc:-. Company/Policy Number) Date)
(Name of Contractor) (Insurance Comrany/Policy Number) Date)
(finach additional slsrm p•=tainint; .1;oxr.raci;:•)
()4 I ant a sole propiie:oi and have no one working for inc.
( I am a honie owner Deiforming all the work invs-lf
Ve..")c:::ploy ci to dt trAirj,:lltrICC, •11 t •::
not mere then throo unit'tr.which the b4,1)CX rt3:•%:-,3 OC LIU, rtr.tri thacto e:c IK‹ccncrally
cmplOya-s uc thtvc;k:!:':ccstr,:•nntation Act(61.152_:31(5)),amliz;ation by a homeowner Ier a l•ccr4
legal status of an ear:ploys(under tee Wc.ikc Compensation Act_
I understand that a copy of this state:mot may be forwarded to the Dela:at:nem of Ind...atrial Accidents'Office of air:.for the
coverage vaification end that failure to tectu .de covcrtge urzr section 23A of ht01,152 can lad to the imposition efcrinlinal penalties
comistina of&lux of up to$1.500.00 andw imprison:nal:of up to one year and civil penalties in de fc.nn of ft Ste;V•Icibordt:arid a
fine of S100.00 day tgs.in.st t .
Fur deviutitiestal%Ire,,ftly
• •
• 4//2 170- Permit Nitintxu- .
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Signature of i ;11-•tte'' •
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• � CO ofNorthampton
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$tir*Z B Jillassad1usttte
' t DEPARTMENT OF BUILDING INSPECTIONS = i //
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INSPECTOR 212 Main Street • Municipal Building 7
,�4=5,,:
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as Li /her construction sup:: ..::;or. 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)z
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