11C-001 (3) s st, B P- 2010 -0218
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTg4CXING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT H ESS TO THE GUARANTY FUND I" GL c.142A)
Category �. UILDING PE IT
Permit # BP-200
Project # JS 10 -00027
Est. Cost: 33200
Fee: $240.00 MISSION
Const. Class: Contractor: License:
Use Grou : Homeowner as C ntractor
Lot Sizes . ft.: 410770.80 Owner: GABLE i
Zonin : U 100 / Applicant: GABLE VIKI J
AT. 92 FLORENCE ST
App ant A ress: Phone: Insurance:
92 FLOREN ST (413)586- 8
LEEDSMA0105 ISSUED ON. 813112009 0.00:
TO PERFORM THE FOLLOWING WO RK• STRUCT 30 X 40 GARAGE /STORAGE TO
EXISTING
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 8/31/2009 0:00:00 $240.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -0218
APPLICANT /CONTACT PERSON GABLE VIKI J
ADDRESSIPHONE 92 FLORENCE ST LEEDS (413) 586 -9198 Q
PROPERTY LOCATION 92 FLORENCE ST
MAP 11 C PARCEL 001 001 ZONE URAO 00)/
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: CONSTRUCT 30 X 40 GARAGE /STORAGE TO EXISTING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
Signature of Building Off 'al 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.
a
City of Northampton P 4 D x r�
A ll
r ilding Department C€�
212 Main Street
1 �§
Room 100
Northampton, MA 01060
U G 2 6 064e 413 -587 -1240 Fax 413- 587 -1272
A �
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I M� r.fY^,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Proaertv Addre This section to be completed by office
Map Lot Unit
Q, c� /* Zone Overlay District
U/o Ste.
Eirr St. Distric CB District
.SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) Current Mailinq Address:
Signature Tel ephon I r `I jt
2.2 Authorized Agent: Ze
Name (Print Current Mailing Address:
Af
( 7 7.;�)
Signature V Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed b permit applicant
1. Building s¢�D (a) Building Permit Fee
2. Electrical s (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 FaC'OfFciaf Use Onl' "" "
Building Permit Number. Date
Issued:
Signature:
Building Commissioner /Inspector. of. Buildings--: - Date
a
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 Ci � ®
Frontage
Setbacks Front 7 1 -
r
Side L: .._ R . L ' R:
Rear
Building Height --
Bldg. Square Footage %
Open Space Footage _ %
(Lot area minus bldg & paved
_p arkin g )
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES
IF YES, date issued:f
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW f"% YES
IF YES: enter Book I Page's and /or Document # _._.
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW w YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued
AON
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location
D: re tfiere any proposedchanges to or a pions osigns ihten edTo tie property ? YES NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is ii 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 F Addition ® Replacement Windows Alterations) ❑ Roofing
Or Doors ED
Accessory Bldg.o& Demolition ❑ New Signs [O] Decks [C] Siding IVJ Other [a
Brief Description of Proposed / i
Work: >/X
Alteration of existing bedroom Yes Z No Adding new bedroom Yes No
hed Narrative Renovating unfinished basement Yes 4 1 _ NO
Plans Attache {I - Sheet
sa. if,:New house °aiid or additlon�ta- exlstfnq" housing,. complete fHe folioitiing:
a. Use of building: One Family Two Family Othe
b. Number of rooms in each family unit: Number of Bathrooms 0
c. Is there a garage attached? Ae
d. Proposed Square footage of new construction. , Dimensions .J � / )
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 constructionb
i. Is construction within 100 ft. of wetlands? Yes ^ No. Is construction within 100 yr. floodplain Yes 14No
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 my behalf, in all matters relative to work authorized by this building permit application.
SignatOwner Date
I, ti !) T� ►
( =q. le as Owner /Authorized
Agent ITereb d eclare 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.
fiA
Print Name
Signature of wner /Agen Date /�i /O
r
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder Xt-WIN ii
License Nurnber
Address Expiration Date
Signature Telephone
9:.Reaastered.tatne tcipFOVeiaenCi�ntr�ctair z , .... Not Applicable
Company 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...... ❑
ii '
L l fl
The_current_exemption for.` homeowners ", was ext ended 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, p rovided that the owner acts
as supervisor. CAM 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 tame, 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, yo 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 mances; a e _ s General•- Lawslnnotated.
Homeowner Signatur
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of-Investigations
600 Washington Street
Boston, MA 02111
www.mass gov /dra
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers
Applicant Information Please Print Legibly
Name ( Business /Organiiation/Individual):
Address:
City /State/Zip: Phone - #:
Are you an employer? Check the appropriate box: Type of project (required):.
1. ❑ I am a employer with 4._ E] I am a general contractor and I
employees (full and/or part - time).
* have hired the sub- contractors 6. El New construction
2. FD am a sole proprietor or partner- listed on the attached sheet 7. [] Remodeling
ship and have. no en� lwyees These sub - contractors have. .8. [] Demolition
working for me in any capacity. employees and have workers' '
[No workers' comp. insurance - camp - 4 Buii addition
required.] 5. [] We are a corporation and its 10 -El Electrical repairs or additions `
3. I am a haaie ork - 9 Ge- °gs —1 I laPlumbrag repairs or additions
myself [No workers' comp_ right of exemption per MGL 12_ Roof r ��
insuran required.] t c. 152, § 1(4), and we have no ❑
employees. [No workers' 13. ❑ Other
comp. insurance 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 then hire outside contactors must submit a new affidavit indicating such.
: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 .provide tbcir workers' comp..policy number.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
�ormation.
Insurance Company Name:
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site Address: City /Stafe/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 criminal penalties of a
fine up to $1,500.00 and/or one=year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fire
of up to $250.00 a day against the violator. , 15e advised that a copy of this statement maybe forwarded to the Office of
Investisations of the DIA for insurance coverage verification.
I do
_hereby certify under. *eparns andpenalt es ofpedury that the informationprovided_above is true and.correcL___
f
Si tore: < ate: Y
[6. fficial use only. Do not wine in this area; to be eomp ed y city or Town official
ty or Town: Permit/License #
uing Authority (circle one):
oard of Health 2. Building Department 3. City/Town Clerk 4. Electrica Inspector 5. Plumbin; Inspector _
Other -. ntact Person- Phone #•
ti
A
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780C1VIR 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
reg lations The i_n_s=nection nro c-em requi that the building department be calle 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 insuections can result in failure to obtain a c 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
-------- - - - - t-s -in- conjunction_ to_ thelui l.diag_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, VI - ki .
6_4 hk 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.
_Bade
Address of work
location _s
bed r _
NOTES and Data — (For department use)
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