24D-204 224 STATE ST BP- 2012 -0065
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc 24D - 204 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categor BUILDING PERMIT
Permit # BP-2012-0065
Project # JS- 2012 - 000096
Est. Cost: $1000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH SEITZ
Lot Size(sq. ft.): 3789.72 Owner: Kass Fred
Zoning: URC(100)/ Applicant: JOSEPH SEITZ
AT. 224 STATE ST
Applicant Address: Phone: Insurance:
196 LINE ST (413) 687 -1227
EASTHAMPTONMA01027 ISSUED ON: 7119120110:00:00
TO PERFORM THE FOLLOWING WORK.- Deck
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 Sienature:
FeeType: Date Paid: Amount:
Building 7/19/20110:00:00 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
O L ` v. L City c f Northampton
ildi ig Department `
212 Main Street
. oom 100
52(111 ;
No ha pton, MA 01060
.oR oars 87- 240 Fax 413- 587 -1272 ;
oN MA 01050
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address
Thissection to be completed'by office
z y� Map Lot Unit
�+
Zar'!e � Overlayprstnct
EIniYSt bi §t lie t CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Rec
Name ¢ t Current Mailing Address:
Telephone
Signatu
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signatu Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
Do
2. Electrical M Estimated Total Costof
Construction from 6
3. Plumbing BuildingPermlt Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 100(5 Check Number
This.Section For Official Use Onl
Date
Building iPermit Number: Issued:
Signature:
Building Commissioner /Inspector:of Buildings Date
4
k
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 ,f (IV
Building Departmdtit w.
' Lot Size r I 5 N 4 7 !
i
H. _A
Frontage I
Setbacks Fron
Side L: _._...._i R: �..__I L: =..=. = ._._ ' = R:
Rear
Building Height
Bldg. Square Footage _i %
-Open Space Footage % - -.-
(Lot area minus bldg & paved
p arkin g)
# of Parking Spaces
Fill: .,.� . �. �._V...�._.�.......W..�.. _�..
7!
volume & Location)
A. Has a Special Permit /Variance /Finding P been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Boo I Pager Document # H
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 Obtained , Date Issued y
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 Q NO e
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, exc ation, 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)
71
a Y
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding [0] Other
Brief Description of Proposed � V¢S
Work: Gtr l � r �-o ae
IF 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 r 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. WilFbuilding 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 CONTRACT OR APPLIES FOR E3tJ:ILDINGPERMI f
I, ' ' uI 1`cl'S as Owner of the subject
property
t�
hereby authorize 3 e J e °
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature f ner Dat
7 . 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 �the and pe nalties of erjury.
Fnnt_!TaAhe
Signature of Owner /Agent Dat
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
r
Name of License Holder _ �1 Tom- cS
License Number
e ( t M 01,02-? 1 C, ? - z L
Addres& Exp ation bate
Signat a Telephone
Not Applicable ❑
9�eirp� ribr�i�tnerton
Company Name Registration Number
Address Exp' ation ate
Telephone
SECTION :10 - WORKERS': COMPENSATIQN 1NSlJRANCE; AFFIDWI.T (M:G.L.
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 buildi54 permit.
Signed Affidavit Attached Yes....... No...... ❑
5:
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
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/Plumbers
A licant Information Please -Print Le 'bI
Name ( Business /Organiiation/Individual): �J t
Address: L `^-• � - �54 J � """""f
7t1 j . 'I .0!� 2.3 Phone. #: q l,3
City /State/Zip: �r,✓ � V%
y�
.Are you.an employer ?.Check the appropriate box:. - Type of project (required):.
4.. I am a general contractor and I '
1. El I am a employer with 6 _ N co nstruction
[� -
- - -- - - * - -- —have hired -the- sub - contractors - -- -
oyees (fiill - and/or part fame). . 7. Remode
2.. am a sole proprietor or partner- listed on the attached sheet
3. ❑ I a homeowner doing all work
q
u ❑
-- " - ship and have. no employees These sub- contractors - have. - .8. ❑ Demolition
employees and have workers' 9: E] Building addition
working for me in any capacity. in suran ce -
[No workers comp- mstuanee COIDp. m 10 Electrical r airs or additions
zegtured] 5. [] We are a corporation and its ❑
officers have.exercised their 11.❑ Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12 [].Roof repairs
insurance required] t P. 152, _§ 1(4), and we have no
employees. [No workers', 13.�ther PC.�r. P a t
Comp, insuranc required. }. -
"Any applicant that checks box #1 must also fin out the section below showing their workers' co aisation policy information.
t Homeowners who submit this affidavit indicating 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 whcd= or not those entities have
employees. If the sub- contractors have employees, they must provide their workers' comp. policy number.
am an employer that is providing workers' compensation insurance for my employees. Below is the policy an
I d job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #. Expiration Date:
Job Site Address: City /Sta&Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage, as required under Section 25A of MGL c. 152 cant lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment; 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
Investisations of the DIA for insurance coverage verification. — — —
I de hereby ce under thepains andpenalties of perjury that the information provided above is true and correct
-Si tore: -Date: Z !1 f
Phone #: 1 3
Offciai use only. Do not write in this area, to be completed by city br town offtcw
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other _ .
� � Contact Person: Phone #: �!
o
HOME OWNER EXElwTPTION 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 buildin g. department for the City .of Ngrthampton wants persons) who: seek to use
the home owner exemption;-to act `as their o"vrrcotrstraction su to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process require s' that. the.building department be called to
inspect work at various stages, which include foundation /footings (before backfdl),
sonotube holes (before , your). 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 worlds 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
in 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 t6 me.
Date
Address of work
location