30C-065 92 CLEMENT ST BP- 2012 -0020
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map-.Bloc 30C - 065 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP- 2012 -0020
Project # JS- 2012- 000044
Est. Cost: $9000.00
Fee: $70.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID MINER 99953
Lot Size(sq. ft.): 42688.80 Owner: KOWALSKI MITCHELL & KATHLEEN & LISA RHOADES & MICHELE
BLAJDA & SUSAN K FALCETTI
Zoning: SR(100) Applicant. DAVID MINER
AT. 92 CLEMENT ST
Applicant Address: Phone: Insurance:
347 NEWTON ST (413) 533 -0481 WC
SOUTH HADLEYMA01075 ISSUED ON. 7119120110:00:00
TO PERFORM THE FOLLOWING WORK.- 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 Signature:
FeeType: Date Paid: Amount:
Building 7/19/20110:00:00 $70.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
E� Northamptont t # "
ildi g Department
21 Main Street
a I�
f 1 201 oom 100
No ha pton, MA 01060 Y .
O , 58 1240 Fax 413 - 587 -1272
ON MAoio6o
� 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
Map Lot Unit
M
EIrt► St Distdct .. c iCb District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record y ,
--- 1 z- f
Name ( rint) Current Maili Addres
Telephone
Signature
2.2 Authorized Agent
Na a (Print) Current Mailing Address:
Signature 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
2. Electrical (b) Estlm Total Costof
Construction from-(6
3. Plumbing Building Permit' Fee Q �
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) l C� Chec[c Number
- This Section For Official Use Onl
0 e Date
Building Permit Number: ,� p Issued:
Signature:
Building Commissionedinspector of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information " 4
Existing Proposed Required by Zoning }
This column to be 1pt44 in by
Building Departmeli
Lot Size
Frontage i $
Setbacks Front
Side L: i_._.._ ' R: .M L: l R:
Rear
Building Height I --)
Bldg: Square Footage _ O/O
-Open Space Footage r---1 %
(Lot area minus bldg & paved i ! L - -
p arkin g)
# of Parking Spaces
Fill:
volume & Location) l—
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT K NOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book r �� Page Document # _
B. Does the site contain a brook, body of water or wetlands? NO 0 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
C. Do any signs exist on the property? YES 0 NO 0
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 0
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 0 NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
I
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) 71
New House [_J Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [0] Other [a
Brief Description of Proposed W
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa if iiir to rse at tl fitlitic #O a Wild �i � g � ", I h r
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
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters rel tive to work thorized by this building permit application.
Signature of Owner Date
as Owner /Authorized
Agent her y declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed u r pains and penalties of perjury.
Print Name
Signature o caner /Agent Date
.o
SECTION 8 - 'CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicabtt? ❑ T
Name of License Molder J� Y I 'A " r' 4
r
p Licens Number
_)/1 46
Address Expiration Date
Signature
9 Telephone
9�. retglerbor�nrtereten 1Ciifirac€ar a P A
��.,, :, 11 Not Applicable
Company Name Registration Number
Address c 1--� Expiration Date .
—� Telephone �3 `-Cry
F tO- .WORKERS': COMPENSATIQN 1NSURANCE;AEEIDAV. T(M GL. c.152, § 25C orkers 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 DwellinPs 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
U Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
- Workers' Compensation. Insurance Affidavit: Builders/ Contractors /Electricians/Plumb.ers
Applicant Information Please Print Le 'bl
Name ( Business /Orgmizationikdividual): '15
Address:
City /State/Zip: 0 1 1 1 Phone. #:
.Are � `' 3
you em to er ?.Check the a ro riate box: -
y p y pp p Type of project (required):
4.. (] I am a general 7sh
s lam a employer with 2 6._[] N c onstructron
- -- - -
-- employees (full - and/or part=time�
* - -- - -have hired -the - — -
2.. El I am a sole proprietor or partner- listed on the at
Ship and have 7Rtrmodeltng
- -- . -- -- - These sub= cont .8. ❑ Demolition
. . n� e�loyees
employees and. have workers'
working .for me in any capacity. 9. ❑ Building addition
[No workers'_comp. insuuance comp, insuran . 1 _
5. [] We are a corporation and its 10. ❑Electrical repairs or additions
required) _ -
3. f ] I am a homeowner doing all work officers have.exercised their I L[] Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.F1 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. fimuanc required}. -
•Any applicant -hat checks box #1 nnut also fill out the section below showing then workers' compensation policy information.
t Homeowners who submit this affidavit indicating they ate 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 or not those entities have
employees. If the sub-contractors have employees, they must Provide their workers' comp. policy number.
f am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: C
Policy # or Self- ins. Lic. A
U S E4 lion Date: a 1
Job Site Address: f t° . `G �` City /Sta&Zip:' U { s
Attach a copy of the workers'- compensation policy declaration page (showing the policy number and expira n date).
Failure to secure coverage. as required under Section 25A of MGL c. 152' can 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
Investieations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and . orrect
- - -Si ture: Date: .
Phone #:
Official use only. Do not write in this area, to be completed by city or town official,
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 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 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 artment for the City of Northampton wants . person(s) who seek to use
:. _:
the 'home. owner eXemption; to act as their owircoIIShuctron 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 /footinas (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 insyections can result in failure to obtain a certificate of occupancy
until the work can be insuected.
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
1, 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 tor me: _
Date
Address of work
location