11C-036 BP- 2010 -0653
GIs #: COMMONWEALTH OF MASSACHUSETTS
MW,-OW C.�#U CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: shed BUILDING PERMIT
Permit # BP- 2010 -0653
Project # JS- 2010- 000939
Est. Cost: $300.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 23783.76 Owner: YURGIELEWICZ JAMES & NANCY J MILLER
Zoning: URA(100)/ Applicant YURGIELEWICZ JAMES & NANCY J MILLER
AT. 45 FLORENCE ST
Applicant Address: Phone: Insurance:
45 FLORENCE ST (413) 584 -4949 ()
LEEDSMA01053 ISSUED ON. 111212010 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMOLISH 304 SQ FT SHED
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 1/12/2010 0:00:00 $20.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -0653
APPLICANT /CONTACT PERSON YURGIELEWICZ JAMES & NANCY J MILLER
ADDRESS /PHONE 45 FLORENCE ST LEEDS a
41 c, y
PROPERTY LOCATION 45 FLORENCE ST O
MAP I IC PARCEL 036 001 ZONE URA(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
T_ypeof Construction: DEMOLISH 304 SO FT SHED
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 F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION 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.
City of Northampton
Building Department
212 Main Street Alratlabi
Room 100 r S '%���'
Northampton MA 01060..
phone 413- 587 -1240 Fax 413- 587 -1272 �
' Pt 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
old tz f -1 Ma Lot Unit
G
_ p
Zone Overlay District
EIrMStDistrict CB District
SECTION '2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address
Telephone T
Signature
2.2 Authorized Agent:
. J A IN 2010
Name (Print) Current Mailing Address: 1.
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 l (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) (rf O Check Number
This Section For.' Official Use Orrl�
Date
Building Permit Number: Issued:
Signature:
Budding Commissionergnspectorof Buildings Date
d
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 _ R L R.
Rear
i Building Height
Bldg. Square Footage i"
Open Space Footage %
(Lot area minus bldg & paved
-kin
# of Parking Spaces - -
Fill: I
E
(volume & Location)
A. Has a Special Permit /Variance /Finding ever 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 DONT KNOW YES
IF YES: enter Book § Page and /or Document # r_
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 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 NO
IF YES, describe size, type and location: "
_ "`� D: ere afi�` ny prop`os changes o or a ttlons o signs inten ed"for tF `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 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
a
s
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable►
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing El
Or Doors D
Accessory Bldg. ❑ Demolition .� New Signs [O] Decks [M Siding [0] Other [o]
Brief of Proposed E /m 4c k r - r jN a S��t� b b �� �/ m l`
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
If N isfiinciN io&64 ete tale f656 war g:
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?
1 f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
j' h. Type of construction
l �
1 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 relative to work authorized by this building permit application.
Signature of Owner Date
L'Z 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 Name''
nature of Owner /Ag Date
s
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
6:. Registered HomE`:tnproueirrent Cntractor F . „ .r ._, .. .... Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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...... ❑
'UI$�
1 ,11 1 AM
--
-The-current-exemption for.`_homeowners "w extended t o 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. CAM 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 -vear 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
ort arripton r mances, Sc°afi eral Laws- Annotated.
— / Homeowner Signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
_ 600 Washington Street
Boston, MA 02111
'�; s�•' www.massgov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumb.ers
App licant Information Please Print Le�ibiv
Name ( Business /Organintion/Individual):
Address:
City /State/Zip: Phone. #:
Are you an employer? Check the appropriate boa: Type of project (required)
1. M I am a employer with 4.. ❑ I am a general contractor and I
have hired the sub- contractors 6. New construction
employees (full and/or part time). *
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E] Remode a
�
ship and have no p^ ployees These sub - contractors have .g. DemoMon
working for me in any capacity. employees and have workers 9 ❑ Building addition
[No workers' comp. insurance GO insurance... 10. repairs or additions
required.] 5. ❑ We are a corporation and its ❑ Electrical p
3. I -am -a- homeowner -Being -all work - —
_ -- 9_ crams ay c is their L13.E) lumbiag repairs or additions
myself [No workers' comp. right of exemption per MGL oof repairs
insurance re ed t c. 152, § 1(4), and we have no
4 ] employees. [No workers' ther
comp. insu rance required.]
'Any applicant that checks box #1- must also fill out the section below showing then- workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors roust submit a new affidavit indicating such.
( Contractors that chock this box mast attached an additional street showing the nine 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.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
Insurance Company Name:
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site Address City /State /Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requited under Section 25A of MGL c. I52 can lead to the imposition of criminal penalties of a
fine up to $1 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fire
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 the DIA for insurance coverage verification.
I do hereby _certify under the pains and penalties of perjury that the uformation provided-above istrue-iind -correct - -_ -._
Signature Date:
Phone #:
FOther us e
only. Do not write in flits area, — fo be comp eied y city or town official
T own: Permit/License #
thority (circle one):
- Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
son: Phone #:
Y ti
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 Th_ a insnecti on_pmcess_reV m s that the building department be calle to
inspect work at various stages, which include foundation /footings (before backrdl),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspect 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
its- in-conjunctioa -to- the - bu ilding per it 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
9
L 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