11C-023 9 HEFFERNAN ST BP- 2011 -1109
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map.Bloc 11C - 023 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit# BP- 2011 -1109
Project # JS- 2011- 001785
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 8973.36 Owner: FARRELL SUSAN M FARRELL
zoning: URA(100) Applicant: FARRELL SUSAN M FARRELL
AT: 9 HEFFERNAN ST
Applicant Address: Phone: Insurance:
9 HEFFERNAN ST (413) 687-7083
LEEDSMA01053 ISSUED ON :612912011 0:00:00
TO PERFORM THE FOLLOWING WORK.- INSTALL PELLET STOVE
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 6/29/20110:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
�CE ity of Northampton"
R
uilding Department s�
212 Main Street
Room 100:
ECCwJort ampton, MA 01060
�pr.opt - 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
ML ot - Unit
1 p� Zone Overlay District
e' �k S t 6 I 0 J � Efrn St District CB Distri ct
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
� G A FYI . � 'A C rn.
Name (Print) Current Mailing Address:
Telephone
Signature
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
com feted by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (6) 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
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomp to Information
Existing Proposed Required Zonin '
This col o be fiilledf
Building D artmfnt x
Lot Size
Frontage
Setbacks Front
Side L: R: L:"___._"...= R :
Rear '
Building Height
Bldg. Square Footage 01/0
Open Space Footage %
(Lot area minus bldg & paved
-kin
# of Parking Spaces ?- - - - - -- I -'
Fill: W.
volume & Location
s
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KN 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 Page; and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO �9 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 0 NO l ick
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 5�
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF` PROPOSE D WORK (check all amlicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ T Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Ca Siding [O] Other [
W i o e r f k Description of Proposed =� �A t z Imo` C,��., ✓��
Alteration of existing bedroom Yes No T Adding new ,- bedroom Yes �� No
Attached Narrative Renovating unfinished basement Yes _X No
Plans Attached Roll - Sheet
6a. if 1 y�r i ix ar.3ac tl� is °tc existE a `C axis rrii. c'oini� -> IOWA,
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
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 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 o Owner /Agent Date
' a
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
yRealsteiedHmIritircirhiientCiifCt _ _' _ .�, ,. K ,,. 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...... ❑
w, W'S ;
T�lll�II;G� On
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.
i omeowner Signature ��J•�Od-- r�/VL4 `�
The Commonwealth of Massachusetts
Department oflndustrial Accidents
fn
Office oflnvestigations
600 Washington Street
Boston, MA 02111
www.mass gov /dia
- Workers' Compensation Insurance Affidavit: Builders /Contractors/Elect icians/PIumbers
Applicant Information Please Print Iv
Name ( Business /orgaaiiationandividuai):
Address: r
City /State/Zip: Phone. #:
L3:a n employer ?.Check the appropriate'boz: - Type of pioject (required)•.
a employer with 4.. E] I ara a general contractor and I
loyees (fall and/or part time)."
have hired the sub- contractors 6. C] New construction .
a 'sole proprietor or partner- listed on -the attacheii sheet 7. ❑ Remodeling
gad have no employees These sub - contractors lsave. .8. Demolition
ing for -me m any capacity. Ioyees -and have workers'
_ . � l�uil a�dfion
workers' comp insivance - 'cQ]V.
re&] 5. We are a corporation and its 10 Q' Electrcal repairs or additions ofcers have�ercised their 0 nig a homeowner doing all work l 1. Plii>vb epairs or additions
' r lf [No workers' comp. right of exemption per MGL 12.D. Roof repairs
n�• regarded t -c: 152, §1(4); and we have no -
_ emVloyees. [No workers'. 13. El Other
comp. insurance regtiied}.
*Any applicant chat checla box #I—st.also fill out the section below showing their wodac -compensation policy information:
t Homeowneri who submit this affidavitindicating they are doing an work and then bue outside contraciois must submit a new-a$idavit indicting such.
zcont<actors that check this box must attached an additional sheet showing the name of the sub-contractoc; acid state wheel= ornot- *= -emitia have
employees. If the sub -cm ractrns have employe.., they nn�si provide their wmi,=' comp-policy number-
law an employer that isprovidfng workers' compensation furs mwe for m employees Below is thepolicy and job-
information.
Insurance Company Name
Policy # or Self -ins. Lic. # E.Vi ation Date:
r
Job Si ft Address: City/Stafe/Z p .
Attach a copy of the workers compensation policy declaration page'(sh the h number and iration date .
Wig: p9 4 cY . _ . __ xpi _ i _ - ) .
-
Failure. to covert e;as re i d`ci Seatron`25A ofMGL`e. I52 cat lead to the smom'of .
g - o ` . penalties of a
fine tip to $1,500.00 and/or one- year as well as civil .penalties in the form of a STOP'((? ORDER and a fine
of o $250.00 a da ' against the violator Be advised that a
uP tar Y g copy of this statement may be forwarde to the O.ffice.O
�vmfigtions ofthe DIA for msman - - "`
s e - coverage verb cation: _
0 Tier cerh under the ours andaltr$s o _
tha - the ` infornrartion pro
vrded�bov ;�r
Snattae: I?ate
Phone# ,
ici'al use on ly. Do not write in this to be co town ^' ` a
O -area, _ . .
ff y mpleted by -city or town official
City or Town: Pe'rmit/Llcense #
Issuing Authority (circle one):
J. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical Inspector 5. Plumbing Inspector
6.Other E
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 fancily
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."
The building department for the City of Northampton wants persons) 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 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, Pa - Ir 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:
Date
Address of work
location