10B-032 GROVE AVE BP- 2011 -0327
GIs #: COMMONWEALTH OF MASSACHUSETTS
"#��- WV CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate-gory: BUILDING PERMIT
Permit # BP-2011-0327
Project # JS- 2011- 000537
Est. Cost: $5500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CO -OP POWER INC & NORTHEAST BIO DIESEL 74028
Lot Size(sq. ft.): 25351.92 Owner: CANBY COURTLANDT & NATALIE CANBY & HENRY CANBY
Zoning: URA (100)/ Applicant: CO -OP POWER INC & NORTHEAST BIO DIESEL
AT. 42 GROVE AVE
Applicant Address: Phone: Insurance:
P O BOX 688 WC
GREEN FIELDMA01302 ISSUED ON. 101812010 0.00:00
TO PERFORM THE FOLLOWING WORK: INSTALL SOLAR PANELS
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 10/8/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
City of Northampton
Building Department
212 Main Street h ey
Room 100
x
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
Map : Lot Uni
IR cl 4
Zone;: s Overlay District
Eim"St: District CIS District ..
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Pri ) Current Mailing Address: ! Sj
Telephone
Signature
2.2 Authorized Agent: � n
—
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item timated Cost (Dollars) to be Official Use Only
/completed permit 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 + 5) Check Number 1 7Y 5 5
This Section For Official Use Onl
Date
Building Permit Number: Dat 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
s¢ �
Setbacks Front
i
Side L: 7 R.: L: _ _ ; R:
Rear -- -• -••� .`- .._ —..�
Building Height ---- i F ---- 1
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg & paved ~ ? I
par
# of Parking Spaces — -- -
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO P DONT KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book Pag and /or Document #_
B. Does the site contain a brook, body of water or wetlands? NO DONT 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:���
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q 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 0 NO
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
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [O] Other [0]
Brief Description of Proposed
Work: Dovz
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement es No
Plans Attached Roll - Sheet
tia` � ; 4 lf- hf�'r�C�+����t�;�r•'.�IC�t���� ` 7C�fi����c"�ttl� � ��t�tl��iQ.
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: ( q • Number of Bathrooms
/u
c. Is there a garage attached? / 0
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? ► A14_" Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction d U
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
I as Owner of the subject
property
hereby authorize
to act on y behalf, in all matters relative to work authorized by this building permit a pli tion.
Signature of Owner Date ONE
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 g t Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor I Not Applic
Name of License Holder ✓� -V� '1�� ° C/
License Number
Address Expiration Date
S ignature Telephone
$ It atistebed tttn :lr: nrav ri i rt Cekii>lractt r � `' '- �- Not Applicable ❑d-O
z a R 4*-
Company Name Registration Number
Cl
Expiration Date r
(' �2 S' (�✓S+ P Telephone J� 0�
SECTION 10- WORKERIS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25CM)
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 "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 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
T
The Commonwealth of &fassachusetts
Department of Ind ustrial Accidents "
Office of Investigations
600 Washington Street
Boston, MA 02111
,. www.mass gov /din
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumb.ers
Applicant Information ^ p Please Print Leeibly
Name ( Business /Orgmizatiow7ndividual): eve t-
Address:
City /StateJZip: r ._J ^�'� ` r (CA Phone. #:
Are yo employer?. Check the appropriate 'box. Type of project (required):.
1. I am a employer with (o - 4.. ❑ I am a general contractor and I 6. El New construction
employees (fall and/or part-time). # have hued the sub contractors
2.. El arsi a sole proprietor or partner- listed on dw attached. sheet. 7- Remodeling
ship• and. have no. e�loyees These sub - contractors have. .8. ❑ Demolition
working for me in any capacity- employees and Isaye workers' 9. ❑utlding a�didon
_ CQmP. .:_#
[No wflr- leers' eomp. insu �snrance'. -
required:] 5- ❑ We are a corporation and its 1 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers havexercised their 1 L Plumbing repairs or additions
myself: [No workers' comp. right of exemption per MGL 12.E] Roof airs
insurance re ed t c: 152, § 1(4), and we have no 13. E / 11 PC
emp loyees. o workers' �d d �4
comp. insurance requited. }.
"Any app &cant -that checks box #f1 must also fill out the section below- showing their workers' compensation policy information:
t Fionswwaers vbo submit this affidavit.indicating they are doing all work and then biro outside contractors must submit anew affidavit indicating such.
ICoaGactnrs that check this box must.attached an additional sheet showing the name of the sub = contractors and state whether or not those amities have
employees. I 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 thepolicy andjob site
information.
Insurance Company Name:
Policy # or Self-ins. Lic. #: Expiration Date: n
Job Site Address: t.►C - /b y (' CT "P City /Staw ap:
Attach a copy of the workers," compensation policy declaration page '(showing the p9licy number and expiration date).
Failure to secure coverage. as required nnder.Seclaon Z�A'of 1GICrT c: 152 can lead ° to t11e imposition of crimm�I penalties of a
fine up to $1,500.00 and/or one - year imprisonment, as well as civil penalties in the form of STOP WORK ORDER and a fine
of up to $250.00 a 6 against the violator. Be advised that a copy of this statement may be forwarded to tau Office of
_ r -,
I ve si cations "of the'D A for hisuralice c overs ee verification.
I do hereby certi rider th p d Pena Me ofP ury that information provided abavE irlrus_and carrec____ .. _.
Si tire: !( ate
Phone #:
Official use only. Do not write in this area, to he completed by city or town'bffciaL
City or Town: PermitUcense #
Issuing Authority (circle one):
:1. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical Inspector 5. Plumbing Inspector
6. Other r-
Contact Person: Phone #:
w
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 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 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
�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
I, understand the above.
.(Home owner /resi pt's signatu a requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued tome.
Date
Address of wor
location ("'2t "
MA- ��es3
OCT 8 2010
4 C' VATE IMMAWYYYy
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Blackmer insurance Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
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