11C-039 ` 47RD UNCE ST BP-2011-0158
GIs #: COMMONWEALTH OF MASSACHUSETTS
A : k- �c = Q 9 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INTERIOR DEMOLITION BUILDING PERMIT
Permit # BP-2011-0158
Project # JS- 2011- 000164
Est. Cost: $2500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 16552.80 Owner: DONALD P JUDGE
Zoning: URA(100) / Applicant DONALD P JUDGE
AT. 73 FLORENCE ST
Applicant Address: Phone: Insurance:
23 East Center St (413) 586 -2597
LEEDSMA01053 ISSUED ON. 8/27/2010 0:00:00
TO PERFORM THE FOLLOWING WORK.- HOUSE & DEMO INTERIOR
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 Si
FeeType: Date Paid: Amount:
Building 8/27/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP- 2011 -0158
APPLICANT /CONTACT PERSON DONALD P JUDGE
ADDRESS /PHONE 23 East Center St LEEDS (413) 586 -2597
PROPERTY LOCATION 73 FLORENCE ST
MAP I IC PARCEL 039 001 ZONE URA(100)/
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:_ RAISE HOUSE & DEMO INTERIOR
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
INFCMATION 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
�m ot4,c,�. / Ito
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.
City of Northampton
Building Department
212 Main Street
Room 100
NWhampton, MA 01060 A
p phone 4 87 -1240 Fax 413 - 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address
-7 3 FUV (,6 N C CH7<F;� Map Lot Unit
010
t 0 ; ` Zone Overlay District
EIm;St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) Current Mai in Address:
13 SS,6 o` , 27
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 leted by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing l3uiiding Permit Fee
o0
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 Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Dep ent
Lot Size J �'
Frontage
Setbacks Front
Side L: R: L:
Rear
Building Height
Bldg. Square Footage l %
Open Space Footage %
(Lot area minus bldg & paved a W _
p arkin g)
# of Parkin aces ---
Fill.is
volume & Location)
A. Has a Special Permit /Vari ce /Finding ever been issued for /on the site?
NO Q DON7 KN 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Rggistry of Deeds?
NO Q DONT KNOW `,\ YES / J
IF YES: enter Book r � Page € and /or Document #;
B. Does the site contain a brook, body of water or wet l ds? NO 0 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obta' ed frorrn the Conservation Commission?
Needs to be obtained 0 ined Q , Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type nd location
D. Are there any propose changes to or additions of signs intended for the property ? YES NO
IF YES, describ size, type and location:
E. Will the cons ction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will di urb over 1 acre? YES Q NO 0
IF YE , then a Northampton Storm Water Management Permit from the DPW is required.
r
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition J9W New Signs [0] Decks [M Siding [0] Other [o]
Brief Description of Proposed 6 N i HNSG
Work. y \ T
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa...if N ` tiQluse- alhc��a�r.:�ai�tli d " °>fa�isxlrr� hafsallC �+cOini folvwiri �:
a. Use of building : amity Two Family Other
b. Number of rooms in each fam nit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. D' nsions
e. Number of stories?
f. Method of heating? Fire s or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck gy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. etlands? Yes No. Is construction within 1 r. floodplain Yes No
j. Depth of basement ellar 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 APP LIES >FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to wo7!h ' y this building permit apple
Signature of Owner Date
as Owner /Authorized
Agent hereby declare that the atements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains ar penalties of perjury.
��►�l ia(dr
Print Name
- 3l Iv
Signature of Own r/A nt 1 Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of Llcen
A License Numb
Address iration Date
Signature Telephone
RQiSek#ittlt 11Tiitlli@1ktDrir3tOt, x
,g -Nof Applicable ❑
Company Name Registration ber
Address Expiration Date
Telephone
SECTION 10- WO ERS' 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...... ❑
nm
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" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State an ocal ws and State of Massachusetts General Laws Annotated.
Homeowner Signature
' r
The Commonwealth of Massachusetts
Department of Industrial Accidents .
U. Office of Investigations
600 Washington Street
Boston, MA 02111
www mass gov /dia
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers
Applicant Information Please Print Legibly
Name ( Business organinfion/individual): .
Address:
City /Sta&e p: Phone. #:
Are you an employer?. Check the appropriate box: Type of project (required) :.
1. ❑ I am a employer with 4.- [] I am a general contractor and I 6. E] New construction
employees (full and/or part time)." have hired the sub- contractors
2. Q I am a sole proprietor or partner- listed on the attached sheet. 7. E Remodeling
ship and have no � loyees These sub - contractors have. .8. 0 Demolition
wor for -me in an employees. and have workers' 9v _
any 9 -Q Building addition
[No wo rkers' comp: inna-Mce - con3p. mturance #._.. _.__ ....
required:] 5. Q We are a corporation and its 10.0 Electrical repairs or additions
officers havexercised their
3 . I am a homeowner doing all work fi 11.0 Plumbing repairs or additions
myself- [No workeis' comp. right of exemption per MGL 12: [].Roof repairs
4 , and we have no
;narr,•an required-] t c. 152, $ 1 ()
employees: [No workers' 13.0 Other
comp. insurance reg6irved j
*Any applicant -that checks box #,I: .Also fill out the section belowshowing theirworkers" -convensation policy information.
t Homeowners who submit this affidavit.indicating they are doing all work and then hire outside contractors must subrmt a new affidavit indicating such.
ZContactors that check this box must attached an additional sheet showing the name of the sub- conuactors and state whether or not thoseenttics have
employees. If the sub - contractors bave employees, they must provide their wori=' comp. policy number.
lam an employer that is providing 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 /StafelZip:
Attach a copy of the workers ' - compensation policy declaration page'(showing the p9hcy number and ezpiration date).
Failure. to secure coverage: as required'un&i7 Section 25A of1G CM 15Z can lead'to flie imposition of criminal penalties of a
fine up to $1500.00 and/or one -year imprisonmc. as well as civil penalties in the form of a STOP WORK -ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investieatioris of the DIA for insurance` coverae verification
Ido hereby certi _ - - the Pen vfperjrc>g'thatthe information provirledsibove _rslruearid correct___
Da te : _
Phone #: 7 —
Official use only. Do not write in this area, to be completed by city or town official
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
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
I, understand the above.
.(Home owner /r ent's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date
Address of work
location