10B-011 30 SON RD • BP- 2011 -0643
GIs #: COMMONWEALTH OF MASSACHUSETTS
wak& >ol _l l 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- 2011 -0643
Protect # JS- 2011- 001043
Est. Cost: $3500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 12283.92 Owner: GERBASI GENEVIEVE JODY
Zoning URB(100) //WP Applicant: GERBASI GENEVIEVE JODY
AT. 30 AUDUBON RD
Applicant Address: Phone: Insurance:
30 AUDUBON RD (413) 586 -7958 O
LEEDSMA01053 -0075 ISSUED ON :1/19/2011 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WOODSTOVE
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 1/19/20110:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
; ?epfbent use only
City of Northampton ,
Building Department Curb Cut Driveway Oerrnit
Z..jA -: 212 Main Street ,Seweea4p
rlSAvait -bitty Y �
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Room 100 11VaterlWe iritebtfy
-, Nounampton, MA 01060 Tv�rti bets of #�+ f
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phones 413- 587 -1240 Fax 413- 587 -1272 Plat/Site Mans
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APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION 7
1.1 Property Address: This section to be completed by office
JO �4/4UAO AI 4 Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
�'E/V� ✓E ✓�
Name (P t) Current Mailii Add r ss:
Telephone
Si ature
2.2 Authorized Agent:
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 (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 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 -
Frontage _ ....... __. _ ., a.. ne ........
Setbacks Front
m - -,
Side L. ., ,,___.. R. - -. L: _ R ._ .............
Rear
Building Height
Bldg. Square Footage V O X
Open Space Footage __. -_., _......_...
(Lot area minus bldg & paved
p arkin g)
# of Parking Spaces
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding e%ned d for /on the site?
NO Q DON'T KNOW U
IF YES, date issued:'
IF YES: Was the permit recorded at the g?
NO 0 DON'T KNOW ES IF YES: enter Book ` and /or Document #°
B. Does the sit e contain a brook, bod of water DON'T KNOW YES
IF YES, has a permit been or n ed to be ohe Co ervation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on th1prperty? YES NO IF YES, describe size, ocation:
D. Are there any proposed o or additions of signs intended for the property ? YES 0 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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [0] Other[
i
Brief De ription of Pro
Work: iP£ ✓ /o U.S 1'fONE(,1�ilNF2 /1122 1- 4M iNC7j 9E for 4x W64.31 -• emalet, P lr Got
4 �iq/guCiNGj
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 eAstina housing. complete the followlnt-1:
a. Use of building : ne Family Two Family Other
b. Number of rooms in ea amily unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new constr on. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. asscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is cons ction 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
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
I, , 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, 71/ t� ✓� �'`l as Owner /Authorized
Agent h reby declare that the state ents and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed rder the pains and penaltie ofperjury.
Print Name
Signature X Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Ho r :
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable
Company Name Registration Number
Address Expiratio ate
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT,(M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affida it must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the bui ing permit.
Signed Affidavit Attached Yes....... V 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 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 buildine 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" ce - ics and assumes responsibi)'ty for compliance with the State Building Code, City of
Northampton Ordinances, State a Local Zoning L and S e of ssachusetts General Laws Annotated.
Homeowner Signature Al R �
The Commonwealth of Massachusetts
UV Department of Industrial Accidents .
Office of Invesdgations
600 Washington Street
Boston, MA 02111
www massgov /dim
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
A Ucant Information A Please Print Le 'bl
Name ( Business /Orgwization/lndividual):
Address:
City /State/Zip:� 01053 u0 s'Phone4: 6Z Lf-
Are you an employer? Check the appropriate box:
Type of picoject (required):.
1. [1 I am a employer with 4.. [] I am a general contractor and I '
employees (full andlor part time).* have hired the sub - contractors 6. New construction
2-El I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have. .8. ❑ Demolition
W king for me in any capacity. employees and have workers' _ 9. ❑ Budding addition
o workers' comp. insurance comp. insurance.$
equired] 5. El We are a corporation and its 10 0 Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11.[] Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12TI Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required].
*Any applicant-that checks box #1 must also 0 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.
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' comp. policy number.
lam an employer that isproviding 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. 152 can lead to the imposition of cnn=41 penalties of a
-" -- __fine"uprto 500 .00 -- and/or- ire= yearimprisonme
n� as well as "ci"vil nenaltle`s m the form of a STOP�RK OItDEi� and z tine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investisations of the DIA. for insurance coverage verification.
I do hereby cer nder the pains enalties of rju that the information provided a ? bov . is true and correct
Si tore: Date:
Phone #: +
L er al use only. Do not write in this area, to be completed by city or town of iciaL
r Town• Permit(License #
g Authority (circle one):
rd of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
t Person: Phone #: �� t
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
! express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,. and including the legal representatives of a deceased employer, or the
I
However the
receiver or trustee -of an individual, partnership, association or other legal entity, employing employees:
owner of a dwelling house having not-mo than three apartments and who resides therein, or the occupant of the .
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required." 41
Additionally, MGL chapter 152, §25CM states "Neither the commonwealth nor any of its political subdivisions shall
enter into. any contract for. the performance of public work until acceptable evidence of compliance with the insuran
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and pyone number(s) along with their certificate(s) of
insuranc Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a_p6hcy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self - insuranc license number on the )propriatc Hne.
City or Town Officials
Please be sure.that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write ."all -locationsin city or
town)." A copy pf the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc .) said erso is NOT requized.to_complet his ffida vit___:- __.__�_.___'. -,
The Office of Investigations would like to than you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address, telephone -and. fax number.
• lie Com non`?vealth of Massachusetts
Department 4 f Industrial A.cciden'
Office of Investigations
600 Washingtod Street
13oston, MA 02111
Tel. # 617 -727 -4900 ext 406 or 1- 977- MASSAFE
Fax # 617- 727 -7749
Revised 11 -22 -06 wwumass.gov /dia