05-021 40CItI RD BP- 2010 -0425
GIs #: COMMONWEALTH OF MASSACHUSETTS
A ock: 05 - 02 ;, CITY OF NORTHAMPTON
Lo _001_ PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Ca tegory: BUILDING PERMIT
P ermit # BP- 2010 -0425
Project # JS- 2010 - 000578
Est. Cost: $11000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY J LUCE 100515
Lot Size(sq. ft.): 51400.80 Owner: SEAMANS FRANK A & ROSANNA M
Zoning: RR(100)//WSP Applicant: TIMOTHY J LUCE
AT. 288 AUDUBON RD
Applicant Address: Phone: Insurance:
P O BOX 14 (413) 387 -9800
LEEDSMA01053 ISSUED ON. 1012012009 0:00:00
TO PERFORM THE FOLLOWING WORK :STRIP & 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 10/20/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
,. j' { , -
City of Northampton tasertl
Building Departmentr�F�nnway��
212 Main Street;�eaaxl�_� d
Room 100 t
X,? 'boy. ✓ a" � � `K e d `Y £ ,.,< -
Northampton, MA 01060
phone 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
1.1 Property Address
This section to be completed by office
� "� / [�
L) C tl h0 /��• Map Lot Unit
Zone Overlay District
EImSt'District CB District
SECTION ,2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Qwner of Record:
Name Print) q� Current Mailing Address:
b+d 6�.1��1� -.z. d`L: -,►'ri a—.�4 Telephone
Signature
2.2 Authorized Agent:
Name { Pdn 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 j � (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 + 5) Check Number
This Section Far iJfficial Use Oral
Building Permit Number- IIsssued:
Signature:
Building Commissionerfinspectorof. Buildings Date
J
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 _._....._` ___...._'
Building Height
Bldg. Square Footage E %"
Open Space Footage _ %
(Lot area minus bldg & paved
p arkin g )
. ......... .
# of Parking Spaces
Fill:
g
(volmne & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 D ONT KN OW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
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 0
IF YES, describe size, type and location:
``" D ire t e e any proposed "c�langes to oar acfi ]c�bons ohs into e� fo_ the`p�operty ? 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 1 acre? YES NO
IF YES, then a Northampton Storm Water Permit from the DPW is required.
1
i , a
a
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other [�]
Brief Description of Proposed 1 k t :I
Work: l r" Q yw, r (9� It
IJ
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa. if Hew,house "and ar.:acT lWon, eXistinA housinaa coi»iplete fhe:fol o�niing:
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
1 1Q It/ rt} /9 as Owner of the subject
property
hereby authorize T O ��---
to act on my behalf, in all matter relative to rk authorized by this building permit application.
yL( - lz / L) Llg d 9
Signature of Owner Date
as Owner /Authorized
Agent hereby decl a 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 ��r
Signature o ner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su e rv v isor: Not Applicable ❑
Name of License Holder / ,P f 4 I L V 6— /0V 5 )
License Number
Addre Expiration Date
��'3 3 1
Signature Telephone
m
9sferESi :lomeproyrue>rtGi4ittrac#or .�, Not Applicable ❑
Company Na e n p 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...... ❑
The-current-exemption for-"horn eowners" 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
o ampton r tnances, e n tts Creneral T aws- Annotated.
Homeowner Signature
Y.
a � M
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
_ a 600 Washington Street
Boston, MA 02111
�,•' www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizati divi
Address • X-
l yJ
City /State /Zip: A l f _
Lee-, Phone-`:
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I a employer with 4.. E] I am a general contractor and I
Ioyees (frill and/or part-time). *
have hired the sub- contractors 6. New construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. [] Remodeling
ship and }rave no employees These sub - contractors have. .g. C] Demolition
working for me in any- capacity. employees and have workers' addition
9. Building - - -.
_ comp
e q worker comp. �nc insuran 10. Electrical repairs or additions I
required:] 5. [] We are a corp� oiation and its ❑ " p
3. [� I am a�ioo-wner dei$tr X11 �vef - - -- — _ - 9�sa cxercis��s I1* ezr _ —�1.� ing repairs or additions
myself [No workers' comp. right of exemption per MGL 12. oof repairs
insurance required.] 1 c. 152, § 1(4), and we have no
employees. [No workers' 13.❑ Other
conip. insuran required -I
*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 then hire outside contractors must submit a new affidavit indicating such.
2 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.pravide their workers' comp..policy number.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. ._. -_
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 required under Section - 25A of MGL c. 132 can lead to the imposition of crimiW penalties of a
fine up to $1, 500.00 and/or one:-year impriso n as well as civil penalties in the form of a STOP WORK ORDER and a Ene
of up to $250.00 a day against the violator. lye advised that a copy of *his statement maybe forwarded to tle Offlc�e of
Investigations of the DIA for insurance coverage verification.
ldo hereby_certi rider the airs andpenalties of..perjury that the informationprovided above is_true arid.correcL
Si tore: Date•
Phone #- �/,3 FI
-
Official rise only. Do riot rvrrte in this area, to be completed y city or torn ociaL
City or Town: PermitlLicense #`
Issuing Authority (circle one):
I: Board of Health Z_ Building Department 3. City/Town Clerk 4. EIectrical Inw ector 5. Plumbing
- -- _ 6. Other r
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 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 inspe iozLp Eess rewires that the building department be called to
inspect work at various stages, which include foundation /footings (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-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
----- - - - - -- permi -in - conjunction -to_ the- .twilding._p-ermit_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 me.
Address of work
location
a