05-069 ,.
3 x BP- 2010 -1167
GIs #: COMMONWEALTH OF MASSACHUSETTS
5 as9 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
Permit # BP- 2010 -1167
Protect # JS- 2010- 001703
Est. Cost: $22000.00
Fee: $30.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TEDDY BEAR POOLS & SPA 111889
Lot Size(sa. ft.): 84506.40 Owner: SWENSON CHARLES R & MEREDITH A GOULD
Zoning: RR(100) //WP/WSP Applicant: SWENSON CHARLES R & MEREDITH A GOULD
AT. 695 KENNEDY RD
Applicant Address: Phone: Insurance:
695 KENNEDY RD Workers Compensation
LEEDSMA01053 ISSUED ON. 6/28/2010 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 18 X 33 ABOVE GROUND POOL
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 Sisnature:
FeeType: Date Paid: Amount:
Building 6/28/2010 0:00:00 $30.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -1167
APPLICANT /CONTACT PERSON SWENSON CHARLES R & MEREDITH A GOULD
ADDRESS/PHONE 695 KENNEDY RD LEEDS
PROPERTY LOCATION 695 KENNEDY RD
MAP 05 PARCEL 069 001 ZONE RR(100)//WP/WSP
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: INSTALL 18 X 33 ABOVE GOUND POOL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 111889
3 sets of Plans / Plot Plan
THE FOLLOWING 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
lO
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.
Department use only
City of Northampton Status of Permit:
!. Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
oom 100 Water/Well Availability
�v� J N&tha pton, MA 01060 Two Sets of Structural Plans
phgp6 -4'1 -587- 240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify
APOLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Prooertv Address ,r� This section to be completed by office
b
( 9s- K- -z ti h '?_ J y 1 `- Map Lot Unit
L_ A �1 A i ^�� vj � Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record >
Name (Print) Current Mailing Address:
( � yk -:� -- '-�- x , __ 1 �5 `\s> y3
11 Telephone
Signature
2.2 Authorized Aaent:
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 i A ` (a) Building Permit Fee
2. Electrical v v (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) Z J J ` - J Check Number V7 ff
This Section For Official Use Onl
Building Permit Number: Date
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 •� A c ✓�
Frontage
Setbacks Front
Side L: R: L: R:�(�C�
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg & paved
p arking)
# of Parking Spaces
Fill:
volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO O DONT KNOW @ YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW ® YES Q
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O 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 O 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.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all aoalicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [[3] Other [[I
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
6a. If New house and or addition to existina housing, complete the following:
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. floodpiain 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, 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
1, 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
Signature of Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction u rvisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9. Realstered Home ImD rove ment Contractor; Not Applicable ❑
CompaO 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...... ❑
11. - Home Owner Exemption
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 10835.1.
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 � A WJ-,- C
T
The Commonwealth of Massachusetts
Department of Industrial Accidents .
Office of Investigations
600 Washington Street
Boston, MA 02111
• www.massgov /din
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print L �'biv
Name ( Business /Organization /Individual): .
Address:
City /State;Mp: Phone -M
Are you an employer ?.Check the appropriate'box: -Type of project (required)•. r
am a employer with 4.. 0 I am a general contractor and I
* have hired the sub- contractors 6. New construction
employees (fall and/or part time).
m a sole proprietor or partner- listed on the attached sheet y Remodeling
2.0 I a ❑
have no: employees These sub - contractors have . .8. 0 Demoli�on
slop" � � y
worlang for me in =y capacity. em have wort='.. 0-M audition
[No workers' eo=pr. mmzranc - CoIDP. me�manr• #._ .:- _ -
required:] 5. 0 We are a corporation and its 10.[] -Electrical repairs or additions
officers havexercised their 11.0 Plumbing repass or additions
3.0 I am a homeowner doing all work s . .
myself [No workers' comp. right of exemption per MGL 12:[].Roof repairs
insurance required] t c: 152, § 1(4); and we have no 13.0 Other
employees: [No workers'
COMP. insurance required.} .
*Any applicant -tbat checks box #1 must also fill out the section belowslwwing 6e policy information.
t Homeowners who submit this affidavit.indicating they arc doing an work and then hire outside zontzactois must submmt anew affidavit indicating such:
=Contractors that check this box mmtattached an additional sbeet showing the rye of the sub-conuactv►s and state whethw ornottlwse- entities have
employees. If fie sub - contactors have employees, they must provide their workers' comp..policy mmnber.
I am an employer that is providing workers' compensation insurance for nay employees Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City/Sta&2.ip:
Attach a copy of the workers' compensation policy declaration page - (showing the policy number and expiration date).
Failure to- secure coverage e - as required under Section 25A ofMGL`c 132 can lead theidiposiition of crimn>41 penalties of a
fiat up to $1,500.00 and/or one -year imprisoninci t; as well as civil penalties in the form of ;t STOP WORK-ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a cop_ y of this statement may be forwarded to the O:Mbe of
Iiivestieatioris ofthe DIA for insurance'covera:�e verification. , - _ ;:_:.. ._...:. _ .... _; . .
Ido hereby certify under the pains penalties of perjury dW the informadon provldedlrbav � •p _aadrarr�cL
�ionature Date•
Phone #:
Official use only. Do not write in this area, to be completed by city 0r jr0w n
City or Town: PermitUcense #
Issuing Authority (circle one):
J. Board of Health 2. Building Department 3. CityiTowa Clerk .4. Electrical Inspector 5. Plumbing Inspector
6. Other F
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 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 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
�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
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 tome.
Date
Address of work
location
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