12C-001 84 NORTH FARMS RD BP- 2011 -0870
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map.-Bloc 12C - 001 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- 2011 -0870
Project # JS- 2011- 001428
Est. Cost: $2600.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CYRUS NEWMAN 064690
Lot Size(sq. ft.): 43560.00 Owner: WARBURTON LINDA LEE & BARBARA WARBURTON
Zoning: SR(100)//WP/WSP Applicant: CYRUS NEWMAN
AT. 84 NORTH FARMS RD
Applicant Address: Phone: Insurance:
697 Brid Road (413) 586 -1093 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON :412912011 0:00.00
TO PERFORM THE FOLLOWING WORK: STRI P & SHINGLE 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 4/29/20110:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
City Of Northampton��
Building Department
nail
p Z5 Go 212 Main Streete
LC Room 100 90 orthampton, MA 01060 hone 413- 587 -1240 Fax 413- 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address
Map Lot Unit
Zone" Overlay "District
Elm St :District CB District
SECTION '2 - PROPERTY' OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized A ent:
Name (P nt) _ _ Current Mailing Address:
0 7
Sign tur Telephone
SECTI ESTIMATED CONSTRUCTION. COSTS
It Estimated Cost (Dollars) to be Official Use Only
F=ih
completed by ermit applicant
1. Building ®p (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit. Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2+3+4+
Check .Ni
This Section Fort fficial Use Onl
Date
Building Permit Number: Issued:
Signature:
Buildng Commissioner /Inspector of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomptet[amation
Existing Proposed Required by onin$
This column to 4
filled in by f'S 2QA,
1 11 - I
Building Depa ent
Lot Size
Frontage
Setbacks Front
Side L: L--. = R:--,- LL—L R:�Z
Rear
Building Height
Bldg. Square Footage % r
Open Space Footage %
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit/Variance/ Finding ever been issued for/on the site?
Y–A
NO 0 DON7 KNOW 11Q YES
IF YES, date issued:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO _0 DON7 KNOW YES
..........
IF YES: enter Book 1 Page', and/or Document
B. Does the site contain a brook, body of water or wetlands? NO 0 DON7 KNOW / Q 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:
T D_ =e any proposedcanges to o of signs intended - fog the property ? YES 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 I acre? YES No
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
r
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding [O] Other (0)
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa: 1f. New. house .and- 'or..addrhon ° to °ezisfil rci iousln6, Coi4 k6thefoltouuinQ:
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 P -ERMiT
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
I vi M O as Owner /Authorized
Agent hereby oeclareThat the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the ai s and penalties of perjury.
Print e
Signature of Owner g nt J Date
s
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder :
License Number
1 is Y3 Csc wt ) P
Address Expirati n Dat �
6
g Telephone
9. ,;Re' r'steredrliame Irn" rri" enerttCoritracf�~ ;'- Not Applicable ❑
Combany Na Registration Number
Address �` C z ' z
Expirati n D e
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...... ❑
Lhe_cuuent_exemption for `.`homeoYv_ners" was e xtended 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
Employccs 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
nrt amptan r tnanGes, e . tts General-La- wsAnnotated.
Homeowner Signature
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of In vestigations
600 Washington Street
Boston, MA 02111
www.mass.gov1i a
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Le6ibly
Name ( Business /Organization/Individual): Ll'C� j�✓! ,� '
Address: n, "
�c5to6CZ
City/State/Zip: Phone . #: 516 -'lCJ!9 a
Are you an employer? Check the appropriate bog: Type of project (required):,
1. I am a employer with 4.. 0 I am a general contractor and I
employees (full and/or part- time).* have hued the sub - contractors 6. New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling
ship and have. no en-up loyees These sub - contractors have .8. Demolition
to - ees
working for me in any capacity. y andhave workers'
# . 9. 0 Budding addition
[No workers' comp. insurance comp. insurance.. _
required:] 5. We are a corporation and its 10.0 Electrical repairs or additions
3 _.__ - -_ o �ficers a vexxercise d �iL_ - -�1 g epairs or additions
. Q am emeswaer demg�li ork - - aRlumbin r
myself [No workers' comp. right of exemption per MGL 12 Roof repairs
insuran required:] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insuran required}
*Any applicant that checks box #1- must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and them hire outside contractors must submit a new affidavit indicating such.
IContractors 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' coral. policy number.
lam an employer that isproviding Workers' compensation insurance for my employees. Below is the policy and job site
f
Insurance Company Name: JL
Policy # or Self-ins. Lic. #: 1 Expiration Date: f '7
J ob Site Address:
— 4 1 -
a City /State /Zip: t� t (A6
Attach a copy of the workers' compensation policy declaration page (showing the policy number and irati date).
on
- -- -
Failure to secure coverage: as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a
fine lip to $1,500.00 and/or one. =year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a , re
of up to $250.00 a day against the violator. 15e advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insuran coveraze verification
Ido hereby _certify under thepains andpenalt es ofp. erjury that the infornw onprovided -above rs-true-atrdcorrect___ _.._
Signature: g' Da
Phone #:
Official use only. Do not write tt i1ii area, to be completed y 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 I nspector 5. Plumbing Inspector
- -- 6. Other
Contact Person: 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 persons) 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
x P�nlatinnc Th_. e ;r�sn�ction n �Q Eess mires that the building department be call to
inspect work at various stages, which include foundation /footings (before backfdl),
sonotube holes (before hour), 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
-- - - - - -- - permi in-conjunctionrto_ the_ building_permitissued,.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 me.
mat
Address of work
location
NEWMAN'S CONSTRUCTION
697 Bridge Road
NORTHAMPTON, MA 01060
(413) 586 -1093 " C}
PHONE DATE
TO :
JOB
n / -� NAME / LOCATION
J s y
v✓L�IC� IkIA 6z
JOB NUMBER JOB PHONE
We herel�y submit specifications and estimates for:
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W P R0 POS E hereby to furnish material and labor — complete in accordance with the above specifications, for the sum of:
G
C+ G
-- dollars ($ Cni� ).
Payment to be made as f lows:
All material is guaranteed to be as specified. All work to b completed in a professional -�
manner according to standard practices. Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders, and will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents or
delays beyond our control. Owner to carry tire, tornado, and other necessary insurance. Our Note: This propo ay be �
workers are fully covered by workers Compensation insurance. withdrawn by us if not ac p d within / days.
A CCEPTANCE OF PR OPOSAL —The above prices,
specifications and conditions are satisfactory and are hereby accepted. You are
authorized to do the work as specified. Pa;menl will be made as outlined above. Signatu
Date of Acceptance: Signature
PRODUCT 131 2PT FOLD AT (,)Torn COMPANION - M DV -O -VUE ENVELOPE. PRINTED IN U.S.A. B