05-057 BP-2010-0688
(JIS #: COMMONWEALTH OF MASSACHUSETTS
.plp, k: (15. -437 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
Pei iit # BP- 2010 -0688
Project # JS- 2010 - 001011
Est. Cost: $2700.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg. ft.): 222156.00 Owner: BOLOTIN SHARON
Zonin,: RR(100)/ Applicant: BOLOTIN SHARON
AT. 347 AUDUBON RD
Applicant Address: Phone: Insurance:
347 AUDUBON RD 0 584 -61 17 0
LEEDSMA01053 ISSUED ON. 112812010 0:00:00
TO PERFORM THE FOLLOWING WORK. RENOVATE BATHROOM,REMOVE
CLOSET &UPDATE PLUMBING
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 1/28/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -0688
APPLICANT /CONTACT PERSON BOLOTIN SHARON
ADDRESS /PHONE 347 AUDUBON RD LEEDS Q 584 -6117 Q
PROPERTY LOCATION 347 AUDUBON RD
MAP 05 PARCEL 057 001 ZONE RR(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building
Permit Filled out
Fee Paid
Typeof Construction: RENOVATE BATHROOMAEMOVE CLOSET &UPDATE PLUMBING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQ 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
Demolition Delay
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.
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City of Northampton s v
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Building Department Cvititrttcewaetit K g
212 Main Street Cr
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Room 100�
46 i1l
Northampton, MA 01060vo
phong 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
This section to be completed by office
1.1 Property Address
Map Lot Unit
Zone Overlay District
1, r N1 A c" ,I G l:_) _'->
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
� � - ' �' !;\ {mil {2 y ~� M, . --
} F P S L c,- - — - - - - - -- -
Name (Print) ;� Address:
Telephone yt L G
Signature ' `' 1
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED i CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building U (a) Building Permit Fee
i 1
2. Electrical(b) ,Estimated Total Cost of
a C.' Construction from 6'
3. Plumbing i `) Building Permit' Fee
4. Mechanical (HVAC) 1
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) imber
This Section For Official Use (5n!
Date
Building Permit Number: Issued:
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 be filled in by
Building Department
Lot Size
Frontage
Setbacks Front `
Side L:
Rear
Building Height
Bldg. Square Footage l %
Open Space Footage �_. %
(Lot area minus bldg & paved
-kin )
# of Parking Spaces - - -
Fill: ..-
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO � DONT KNOW 0 YES
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book ' � Page ( and /or Document # . ...___
B. Does the site contain a brook, body of water or wetlands? NO fp DONT KNOW 0 YES 0
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
IF YES, describe size, type and location: '€
- i D. Are t ere any pro pos' a anges to or a rtions o signs iraten ed'for tre 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 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
a
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Q Roofing
Or Doors E]
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [0] Other [O]
Brief De cription of Proposed 77� �•
Work: a 3{c i�x'rtrl Yl NP "�ti / CJ�I1� �
Alteration of existing bedroom _ Yes ✓ No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes ��N
Plans Attached Roll - Sheet
6a. 'If Hew house aril or addrtloi f "ii tlna `hou�irici. CO iriptete: the followind:
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 a thorize
to act o y behalf, in all ma rs rela ' t work authorized by this building permit application.
- ignature of wner 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 and penalties of perjury.
Print N I j
atur o Own r ent Date
j
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9: Recrlsfered [ Koine 'lnpraveinenf.oritraetdr< Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SE CTION 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 "wasext 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 cons idered 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" jertifies and as respo li or compliance with the State Building Code, City of
s CFenerafl_.a-ws- Annotated.
Northampton r a
Homeowner Signat
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 /Electricians/PIumbers
Applicant Information Please Print Legibly
Name ( Business /Organza tion/Individual):
Address:
City /State /Zip: Phone. #:
Are you an employer? Check the appropriate box: Type of project (required).
4._ I am a general contractor and I
1. I am a employer with 6. ❑ New construction
me
employees (full and/or part- ti).* have hired the sub- contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have. no P *Ioyees These sub - contractors have .g_ � Demolition
working for me in any capacity. employees and have workers'
[No workefs' comp. insuran comp. insurance.;
9. Q Building addition
required) 5. We are a corporation and its 10.0 Electrical repairs or additions
• ��cers 1iav��xezc� �1_
ng- repairs or additions
m sel£ o workers' co right of exemption per MGL
y c. 152, 1(4), and we have no 12. [] Roof repairs
insuran required.] t § 13.0 Other
employees. [No workers'
comp. insurance required.}
*Any applicant that checks box #1 must also fill out the section below showing their workers' cornpensation 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 whether or not those entities have
employees. If the sub-contract employees, they must provide their workers' comp. policy number.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
_formation.
Insurance Company Name:
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site Address: City /Stafe/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 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 Jane
of up to $250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of
Investigations of Ik DIA for insurance overage verification
I do hereby certi' der the pains and p " s o perjury that tire information provide above " "e-__
-.
':
Si e: ; `, % ate:
Phone #:
Official use only. : ne): wrrte in thin area, to be comp elect y city or sownficiaL
City or Town: Permit/License -
ermit/License #
Issuing Authority (
-I. Board of Health ldinb Department 3. City/Town Clerk 4. Electrica Inspector 5. Plumbinb Inspector __ __ - - - --
6. Other r
Contact use
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
rea�ilationc_ The inspecti call 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 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
it s- in-- wnjunction.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
/ understand the above.
(Home Z oiner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Address of work
location
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