10-012 507 KENNEDY RD BP-2011-0998
GIs #: COMMONWEALTH OF MASSACHUSETTS
Ma p Bloc 10 - 012 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit # BP- 2011 -0998
Project# JS- 2011 - 001625
Est. Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: OLD HADLEIGH HEARTH & HOME CENTER 98784
Lot Size(sq. ft.): 26397.36 Owner: O'BRIEN EDWARD F & ANDREA M
Zoning: RR(100) //WSP Applicant. O'BRIEN EDWARD F & ANDREA M
AT. 507 KENNEDY RD
Applicant Address: Phone: Insurance:
507 KENNEDY RD (413) 586 -2726 O WC
LEEDSMA01053 ISSUED ON. 612120110:00:00
TO PERFORM THE FOLLOWING WORK.- REPLACE WOODSTOVE
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 6/2/20110:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
City of Northampton
G �
Building Departments Y
20 � 212 Main Street
�( 3 Room 100'
N rthampton, MA 01060
3- 587 -1240 Fax 413- 587 -1272
2 ; afm � �. z
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 4 -SITE INFORMATION
This section to be completed by office
1.1 Property Address
D 7 �,�/v'�� O Y �O /q O Map" Lot > Unit
Zone Overlay District
Elm St. District CB DistrictT
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 O wner of Record D k/ !� Al.
Name Print) _ --- - Current Mailing Address: 1 ^ S C1 Z7 2 - 6
Telephone
Signature
2.2 Authorized Agent:
Name (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 ` � er 4' (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building' Penn it Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = 0 +2+3+4+5) Check Number
This Section For Official Use Onl
Building Permit Number: IIsssued:
Signature:
Building Commissioner /Inspector 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 bi filled in by '
s>� M ♦u Building Depa ` ent -
i
Lot Size 1 x Z 0 # _ _
f
i
9
Frontage
Setbacks Front 1
i
Side L: I R ;___.. L: [__...__ R
Rear
Building Height `2 F a oo es
Bldg. Square Footage --3 F L - - ; % i ----
Open Space Footage % _
(Lot area minus bldg & paved as
p arking) --J
# of Parking Spaces
Fill: . _ .u..
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:; l
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES 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 Obtained Q , 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, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
iQFMO v!' F S T JA.) y 1YJ0 s O S 7
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) it ,
z
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing El
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding [0] OtherK]
Brief Description of Proposed S S
Work: 1 C' // i /L' C? 4 S /' er c. /_ L.
Alteration of existing bedroom Yes X No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes _ No
Plans Attached Roll - Sheet
sa: If Ner o house antl ar AddW6ii to exisflna l ortsinii _cempl�ete #k e.foilor[vir><a:
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'
E 10'1 /= °J as Owner of the subject
property
QG O 1--140 L / C �/ /`c�E l T N G►.vl �' C6W
hereby authorize
to act on my beha , in all matters relative to work au" zed by this building permit 6pplication.
Sig ture of Owner Date
as Owner /Authorized
Agent Wreby 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.
Print Name
Signature of Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder h ty J (CG X �
License Nu
Address Expiration Date
Signature Telephone
Not A p p licable ❑
9 "Reais#erpd`Ho lmg - r :.. . »... „.. ` . a .. ...., ....M.... PP
aj �,l0.�IQL2 -1 - `- Imo 11A CQ•.1.�(` Registration / Number
Company Name
}la. Jt ►+�� �l�i'� y 13 '
Address Expiration Date
Telephone 113 53 U N i
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
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 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.mass gov /dia
-Workers' Compensation Insurance Affidavit: Builders / Contractors /Etectrici.ans/Plumbers
Applicant Information Please Print Legibly
Name ( Busines s /Orgmization/individual): .
Address:
City /StateMp: Phone. #:
Are you an employer?. Check the appropriate•box: T e of pr r -
1. I am a employer with 4.. E31 am'a general contractor and I
employees (fall and/or part time).
* have hired the sub- contractors 6 ❑New construction .
2.0 I a>n a sole proprietor or p artner -
listed onthe sheet 7. O Remodeling
ship and have no eioyees These sub - contractors have .8. ❑ Detiolition
working for -me in any capacity. �logees and:I�ave workers'.
r �� 4 Roil adiiion
, W
L� "' wOlkCSS Cai11p. incwmrancY
required-] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
. )
3.0 I am a homeowner doing all work officers have Gercised1heir
11 Plumbing repairs or additions
myself [No workers' comp. right bf exemption per MGL 12:0,Roof repairs
insurance required-] t c: 152, § 1(4); and we have no ❑
employees: [No workers' 13. Other
comp• insurance required}_
"Any applicant that checks box #Lmust.also fin out the section beiaw showing their Work = .. compensation Poficy information
t Homeowners who submit this affidavit:mdimiing they are doing aH work and thm. bire outside contractors must submit anew affidavit indicating w&
1 C,acmactois that check this box must.attached an additional shed showing the name of the sub-contractors ands- whether cr not.ftw- ecttities have
employees. If the sub -cmt zam have employees, tfiey must Provide ties workers' comp..poHcy number.
Iam an employer that isproviding workers' compensation insurance for my employees Below is the polity andjob site
information
Insurance Company Name
Policy # or Self -ins. Lic. #: Expiration Date: .
Job Site Address: City /Stafe/Zip r
Attach a copy of the workers' :compensation, policy . declaration p4ge showing the policy number and eXPiration date).
Failure_ to secure coverage asregiiirecl under Seahvn'2$A of MGL c 132 can lAd die naposrtiori of criminak penalties of a
fine up to $1,500.00 and/or one -year imprisonmei4 as well as civil .penalties in the form of a STOP 'T9 and a fine
of up to $250.00 a day against the violator Be advised - that a copy of ties statement may be for to the ,0.$i ce:of
TnvestiQations of the bIA for insurance' coverage verification "
- -- —
- 1
1
I do hetle$y certify under the pa ns and pexalties V per wy that the information provrdestZb v -trite iLrorr
Signature: bate
Phone #: -
[6. cial use only. Do not write i i this area, to be completed by city or town official
,City -
Permit/Llcense #
. or Town: -
ng Authority (circle one):
ard of Health 2. Building Department 3. Cigaown Clerk .4. Electrical Inspector 5. Plumbing Inspector
her act Person• Phone #•
' 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 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 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
�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
Date 5_12 4-
Address of work �0 �F' N.c.i� - o Y' �D
location 7