32C-206-001GIS #:
Lot: -001
Permit: Building
Category
Permit # BP- 2011 -0562
Protect # JS- 2011- 000928
Est. Cost: $3400.00
Fee: $55.00
Const. Class:
Use Group:
Lot Size(sq. 1): 3702.60
Zoning: URC(100)
BUILDING PERMIT
PERMISSION IS HEREBY GRANTED TO:
Contractor:
License:
Homeowner as Contractor
Owner: SCHIFFER ELYENA
Applicant. SCHIFFER ELYENA
AT. 1 KARY ST
Applicant Address: Phone:
1 KARY ST _ (914) 629 -2764 O
NORTHAMPTON MAO 1060 ISSUED ON :1212812010 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL BATHROOM
INSTALLATION)
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W.
Underground: Service: Meter:
Rough: Rough: House #
Driveway Final:
Final: Final:
Gas: Fire Department
Rough: Oil:
Final: Smoke:
Insurance:
(SINK & TUB
Building Inspector
Footings:
Foundation:
Rough Frame:
Fireplace /Chimney:
Insulation:
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 12/28/2010 0:00:00 $55.00
BP- 2011 -0562
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
1
File # BP- 2011 -0562
APPLICANT /CONTACT PERSON SCHIFFER ELYENA
ADDRESS/PHONE 1 KARY ST NORTHAMPTON (914) 629 -2764 O
PROPERTY LOCATION 1 KARY ST
MAP 32C PARCEL 206 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REMODEL BATHROOM (SINK & TUB INSTALLATION)
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included•
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR
Major Project: Site Plan AND /OR
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit
Special Permit With Site Plan
Special Permit With Site Plan
Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW
Septic Approval Board of Health
Water Availability Sewer Availability
Permit from Conservation Commission
Well Water Potability Board of Health
Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
C7`` 2 . = / '7� P - e / Ao
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413 - 587 -1240 Fax 413 - 587 -1272
2.2 Authorized Agent:
Name Pri ) Current Mailing Ad ss:
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building �} y �(� , �b (a) Building Permit Fee
2. Electrical � (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2+3 + 4 + 5) , O 0 Check Number
This Section For Official Use Only
I Section 4. ZONING I All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
A. Has a Special Permit /Variance /Findin ever been issued for /on the site?
NO Q DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Re istry of Deeds?
NO 0 DONT KNOW YES 0
F __ _._
IF YES: enter Book Page and /or Document #'
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , 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 Q N0
_
IF YES, describe size, type and location: - -- - -
E. Will the construction activity disturb (clearing, grading, ex tion, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Existing
Proposed
Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
' '�' � �
Setbacks Fron
Side
Rear
L: R: J�:]
L:
I
Building Height%
Bldg. Square Footage
I Z
Open Space Footage
(Lot area minus bldg & paved
p arkin g)
`
%
m
# of Parking Spaces
Fill:
volume & Location)
i
M
A. Has a Special Permit /Variance /Findin ever been issued for /on the site?
NO Q DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Re istry of Deeds?
NO 0 DONT KNOW YES 0
F __ _._
IF YES: enter Book Page and /or Document #'
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , 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 Q N0
_
IF YES, describe size, type and location: - -- - -
E. Will the construction activity disturb (clearing, grading, ex tion, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
iECTION 5- DESCRIPTION OF PROPOSED WORD
able)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [E:] Siding [01 Oth er
Wo Description of Proposed
\YvOm
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
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
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, U V
property
hereby authorize
to act on my b*
I ,
Agent hen
and belief.
,d under t pains
�
nyvlrl�_/T Jul
as Owner of the subject
Date
yotpl Yl1
tatements and information on the foregoing apl
ial 'es of perjury.
Date
, as Owner /Authorized
are true and accurate, to the best of my knowledge
,7,0 //o
>ERVIGEs
8.1 Licensed Construction Supervisor
Name of License Holder
Not Applicable
License Number
Aaaress
Signature
Telephone
Expiration Date
sbeot Hai+rnier�it�estrr s �, ,. T - 4 , R I Not Applicable ❑
.: >_w
Company Name I Registration Number
Aaaress
Telephone
Expiration Date
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...... ❑ 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
resiponsible 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
T
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' 600 Washington Street
Boston, MA 02111
y www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumb.ers
Applicant Information Please Print Legibly
Name (Business/organiiation /Individual) :
Address:
City /Stat&Zip: Phone. #:
Are you an employer? -Check the appropriate'box:
1. ❑ I am a employer with
4.. E] I am a general contractor and I
employees (fall and/or part time).*
have hired the sub- contractors
2_0 I am a sole proprietor or partner-
. on the attached sheet
ship and Have no employees
These sub - contractors have.
working for me in any capacity.
employees and have workers'
[Na workeTS' C07ap. inSl3lanCC
required:]
- coIDp. incrn -.inr # -..
5. We are a corporation and its
I V1 am a homeowner doing all work
officers have Gercised their
myself. [No workers' comp.
right of exemption per MGL
insuran requirecL] t
c: 152, § 1(4), and we have no
employees: [No workers'
comp. insurance reg6irv&J.
Type of project (required):.
6. ❑ New construction
7. ❑ Remodeling
•8. [] Demolition
9: II Hcdmg °addition
10 0 -Electrical repairs or additions
11.0 Plumbing repair or additions
12:D.Roofrepairs
13 Other
`�Y applicant 36at checks box #1- must,aiso fM out the section below showing dnirwork=' compensation Policy information:
;Any who submit this affidavit: indicating they are doing an work and then hire outside contractors most submit a new affidavit indicating mcb.
xContactors that check this box must attached an additional shed showing the name of the sub-contractors and state whether ornot those entities have
employees. .If the sub - contractors have employees, they must provide their workers' comp..policy number.
l am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. A Expiration Date:
J o b S ite Addr City/StatelZip:
Attach a copy of the "
workers compensation policy declaration page the p I li nun�tier and expiration date).
' dl i -_
Failure. to sccUre coverage, as reguriccl'under.Secticd 25A ' MGL` - 152 can Icad to $re iuiliositi on`of crin inalI penalties of a
fine tip to $1,500.00 and/or one.- year as well as civil penalties in the form of a STOP WORK-ORDER and a fine
of up to $250.00 a day against the violator Be advised that a copy of this statement may be forwarded to the Office; of
CnvestiQatzons ofth ebIA for'in''surance coverage v eritication:
o hereby ccrfr ► ui earns un penaTi�es ofperjury.that the informationprovu * _a_ ovE_ u�ft_e_and_iorr c
S� �/ �/ _ .. _ _...-
ignature: _ - Date- 02 O Zl2
_ —
Phone 6q ,5 -1 . 7Z. :. _
use
City or Town:
PermitUcense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
lawn officraL
4. Electrical Inspector 5. PIumbing Inspector
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 called to
inspect work at various stages, which include foundation /footings (before back ill),
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
�ermits 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.
.00nize /resident's signatur requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued tome.
Date Zak 2C2 Z 1 0
Address of work
location