32C-297 BP- 2011 -0343
GIS #: 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 -0343
Project # JS- 2011- 000571
Est. Cost: $2000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ERIC PAYNE 086442
Lot Size(sq. ft.): 6098.40 Owner: EVERETT MALCOLM G
Zoning: URC(100)/ Applicant: ERIC PAYN E
AT: 41 VALLEY ST
Applicant Address: Phone: Insurance:
32 BURTS PIT RD (413) 218 -4276 Q
NORTHAMPTON MAO 1060 ISSUED ON. 10/18/2010 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE BARN ROOF
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 Sisnature:
FeeType: Date Paid: Amount:
Building 10/18/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
T
Y
-I I
City of Northampton
W HIM ,,, �_
Building Department
212 Main Street
Room 100
OCT 3 20 0 k
Northampton, MA 01060'
phone 4'13 -587 -1240 Fax 413 - 587 -1272
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
"Un I/a,t 1 e St Map Lot Unit
J � . � Zone, Qyertay 'District,
EInt,St Dtstrldf CB ? District
SECTION -2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
AJ
Name (Print) _ , Current Mailing dre
Telephone \
Signature
2.2 Authorized Agent-
Name (Print) Current Mailing Address:
4 1 3 Zip ���2- 7C
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building 2 ( v p p (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) 2, 5412 Chedc Number
This Section For Official Use Onl
Date
Building Permit Number: Dat Issued:
f
Signature:
Building Commissioner /Inspector of Buildings Date
F
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 ( [ F - 7
Side L: ._._.__� R: L_ — 1 L: _ _ I R: � ' F
Rear
Building Height
3
Bldg. Square Footage % .....�
Open Space Footage %
(Lot area minus bldg & paved L. i �_ ✓ _i
p arkin g)
# of Parking Spaces
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO � DONT K 0 YES Q
IF YES, date issued :i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNO Q YES 0
IF YES: enter Book �� I Page and /or Document
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued: j
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 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO n
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 Alterations) ❑ Roofing 1Z
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding [[3] Other [O]
Brief Description of Proposed
Work: b-• V v\. a y Z a & �
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a T€tSL�[1]� 0 �fkQ .z gl�tAK1t:
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
1, �/i -ULI�- as Owner of the subject
property l
hereby authorize le V-L C J
to act on my behalf, in all matters relativ work authorized by this building permit application.
Signature of Owner Date
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 an"enalties of perjury.
Print Name
Signature of Owner /Agent Date
ti
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder : C ' �' t ZI - 4
07 License Number
� � �� r (l � -,7
Address Expi tion Date
Signature Telephone
13 rRglectialtgibtte titeslitt;�ct `�� Not Applicable ❑
Company Name Registration Number
11 k2/ u
Address Expirati n date
Telephon
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(fi }) ; ,
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...... ❑
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 buildine 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
The Commonwealth of Massachusetts
Department of Industrial Accidents .
Office of Investigations
u
600 Washington Street
Boston, MA 02III
www.massgov /dia
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers
Applicant Information Please Print Legibly
Name (Business/Organization /Individual):
Address:
City /Sta&e p: Phone. #: 2 k 5 � f 7 T�
Are you an employer?. Check the appropriate'box: Type of project (required)
I. ❑ I am a employer with 4.- E] I am a general contractor and I 6. ❑ New construction
employees (fall and/or part time).* have hired the sub- contractors
2.. I am a sole proprietor or partner- listed on the attached sheet 7. F Remodeling
ship and have no epployees These sub - contractors have. .8. f Deaolition
working for -mein any capacity. employees -and :save workers'
. . 1 nr . I . 9 Q uildmg aoddition
Roo workers-' comp'. a
. inst nc e - c�P• — - _
re 5. [J We area corporation and its 10 Q Electrical repairs or additions
i
officers ay.A=csed their 11. PIumbm repairs or additions
3. Q I am a homeowner doing all work ffi h .; • ❑ . . g eP a
myself [No workers' comp. right of exemption per MGL 12: I Roof repairs
insurance required] t c: 152, § 1(4), and we have no
en:p loyees. . o workers' 13. ❑ Other
comp. insuranc requued.1
'Any applicant -that checks box ff1 rnust.also fin out the section below showing dwir vorkas'_compensation policy information:
t Homeowners who submit this affidavit.in&cating they are doing all work and then hire outside contractors 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 of not those entities have
employees if the sub-cont wtors have employees, they must .p imde their workers' comp. policy number.
J am an employer that isproviding workers' compensation insurance for. my employees Below is the policy and job - site
information.
Insurance Company Name:
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site Address:_ -- City/State/Ztp:
Attach a of the workers' - compensation policy declaration page'(showing the p9licy number and expiration date).
Failure for secure covers e:as re under.Seetion 25A'ofMGL c 15Z cau Lead to the ' osition of
g qutret� vnp crinainai penalties of a
fine up to $1,500.00 and/or one -year imprisonment;' as well as civil penalties in the form of STOP WORK- ORDER: a a fine
of up tD $250 00 a -day against the violator. Be advised that a copy of this statement may be forwarded to t ime Offi of _
Investisations of the DIA fo= insurance coveraze verification. _ ..:... _
I do kereby certrfy;under the pains -and enalizes o ,. f
P... .fPe'r, jury that the rn ormatron rovuledabave�s_true�vrrect�_.
Si titre:
Phone
Official use only. Do not write in this area, to be completed by city or town offciaL
City or Town: P6rm!VUcense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk .4. EIectrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
V 4
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 your), a rough buildinLy 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 insuections 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