31A-300 BP- 2011 -0422
IS #: COMMONWEALTH OF MASSACHUSETTS
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- 2011 -0422
Project# JS- 2011 - 000691
Est. Cost: $6025.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANDY 077431
Lot Size(sq. ft.): 11412.72 Owner: HAMMERSCHMITH JAMES
Zoning: URB(100)/ Applicant: MARK LANDY
AT. 25 JAMES AVE
Applicant Address: Phone: Insurance:
P O BOX 61 (413) 625 -6999 O
ASHFIELDMA01330 -0061 ISSUED ON. 111412010 0:00:00
TO PERFORM THE FOLLOWING WORK.- REMODEL BATHROOM
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 11/4/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
r
File # BP- 2011 -0422
APPLICANT /CONTACT PERSON MARK LANDY
ADDRESS/PHONE P O BOX 61 ASHFIELD (413) 625 -6999 Q
PROPERTY LOCATION 25 JAMES AVE
MAP 31A PARCEL 300 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
Typeof Construction: REMODEL BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessoy Structure
Building Plans Included:
Owner/ Statement or License 077431
3 sets of Plans / Plot Plan
THE FOL WING 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 Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demo ' ion elay -
X
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 wiz
Building Department , ao n
212 Main Street`"
Room 100
Northampton, MA 01060.,
phone 413-587 -1240 Fax 413 - 587 -1272
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
� 'Pt�KoS Tq�f� Map Lot Unit
Zone' Overtay,prstnct
Eirt St "District - .' CB.DistrlcIL_
SECTION 2 .PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Na Print Curre t Mailing Address
U 1 -8b
s Telephone
Sign re
2.2 thorized Agent:
t td3w
Current Mailing Address:
7 —
Signatu Telephone
SECTION 3 - 'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building S (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) N A
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) bOZ.S' Check Number
This Section For Official Use Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspecwr of Buildings Date
Section 4. ZONING All 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 i, 1
Side L• I R: L--.. R:
Rear
Building Height --- _—
Bldg. Square Footage 1 0110
Open Space Footage % r
(Lot area minus bldg & paved
p arkin g)
# of Parking Spaces `- -• ----
Fill: I
volume &Location '
A. Has a Special Permit /Variance /Find *n er been issued for /on the site?
NO 0 DONT KN 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Reg* ry of Deeds?
NO 0 DONT KNOW YES i
IF YES: enter Book £ Page and /or Document #.
B. Does the site contain a brook, body of water or wetlands? NO eDONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, exc ion, 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.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition New Signs [O] Decks [Q Siding [o] Other [o]
Brief D scnption of Prop sed
Work: X) Vwe (thSk1' S V } IN Uq�rt tf�f ' � �Q,1fut? '6 Sk t MW kW ► ,�w M Nth �,atti t��►ik
Alteration of existing bedroom Yes V No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a: `1��I�Oa'1AI' >�`OCt��>Itt�l" B �f� �t�C�Sfi�t�'�I IICgC�11������t�i�fDIT� +F��lflinC�:
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? c �
f. Method of heating? _ Fireplaces or Woodstoves Number of each
g. Energy Conservation Compli ce. 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
_ l
I, I M H �!'1/� l L; SYC N!�7 / 'n as Owner of the subject
property
hereby.auth '2 �R
t ct on my half, in II matters relativ o ork authorized by this building permit application.
..
*Signatr Date W
I, 1 M 14!j./n/ &1K SC ) - I /-I 1 `r) as Owner
-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.
5 1 1n ffy?- .S C 1J,-' "J
PrJ Name _ _
Signatur ro ne Date
/r
" � r
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction ( S � u i pervisor : No Applicable ❑
Name of License Holder �A'pvfy UV)2w i 7 + 1
License Nlate
ber
ltlx lox A���Z lea, btflo +11 la
Expiration
��
Sign pre Telephone
S.. Reaiisfi Ll 6rn"rri6tkcyeette�rttactt�rr k `.� .R�. �M PP
=a.� � Not Applicable ❑
_ (k 1.*9, Mbl%
Company Name � Registration Number
`� %%JaL �1 k 0 .tib t yA. y�� 1b 1 ,
Address Expiration ate
Telephone
SECTION 10- WORKERS' COMPENSATIQN INSURANCE AFFIDAVIT ( G.L. c. 152, § 25C
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 buildi permit.
Signed Affidavit Attached Yes...... J2K No...... ❑
N A
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 hom eowner.
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 responsi ' ity for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws tate of Massachusetts General Laws Annotated.
Homeowner Signature
l�`�
• The Commonwealth of Massachusetts
Department of Industrial Accidents .
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers
App licant Information ' Please Print Legibly
Name ( Business /Orgaaimtion/Indi `
. Mq ' Aa4
Address: wx
City /State/Zip 4 , om6 Phone .#: - M— 6glq
Are you an employer ?.Check the appropriate'box:
. Type of project (required) :
1. El am a employer with 4.. El am a general contractor and I
employees (fall and/or part-time). * have hired the sub- contractors 6. New construction
2.. am a sole proprietor or partner- listed on -the attached sheet. 7. Remodeling
ship and. have no ep4iloyees These sub - contractors have. .8. � Demolition
working for -me in any capacity. ea?PIo_yees and 9
[No workers' insurance comp. Kaye workers' . _
workers' co incnrancc #:_ II__ addition
_..
required] 5. ❑ We are a corpoiation and its 10 -56 Electrical repairs or additions
3. ❑ I am a homeowner darn all work officers havehercised their 11. Plumb r
g g epairs or additions
myself [No workers' comp. right of exemption per MGL 12. Roof
repairs
insurance required] t C. 152, § 1(4), and we have no 13. ❑ Other
employees. [No workers'
comp. insuranc req ired.1
`Any applicant that checks box #1 nxm also fill out the section below.showing tbeir compensation policy infarmation.
t Homeowners who submit this affidavit.indicating they are doing all work and then hire outside contirwtois must submit ' a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether not those entities have
employees. If the sub-contractors have employees, they must provide their workers' comp.,'
omp. PobcY number
lam an employer that isproviding workers' compensad insurance for my employees Below is the policy and job site
information
Insurance Company Name:
Policy # or, Self -ins. Lic. #: Expiration Date:
J S ite A dd r ess: City /Stafe/Zip:
Attach a copy of the workers' compensation oh declaration ge showin the policy number and expiration date).
policy P g
Failure tb secure coverage ,as recluired'imder Sechon'25A ofIvIGL c 152 can lead to die imposition of penalties of a
fine up to $1, 500.00 and/or one -year imprisonment; as well as civil penalties is the form of STOP V,?ORK -ORDER and-a fine
of up to $250.00 a day against flip violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investtaafioiis of the DIA for msutance coverage veiiiscation
- - - -- - the pains and penalties of perjury that the information pray nbaV0 iUtrNe asdCorrea
S _
i _ _..:_ _..
` ate ��
Phone #:�'�
IE
__.._
LOther
- tore:
only. Do not write ui this area, to be co
mp feted b Y ciiY or to wn offcraL
n- Permit/License #
hority (circle one):
J. Health 2. Building Department 3. City/Town Clerk .4. Electrical Inspector 5. Plumbing Inspector
son: 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 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
�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.
.(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