11C-025 a
6 STOWELL ST BP- 2011 -0860
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc 11C - 025 f CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOFING /SIDING BUILDING PERMIT
Permit # BP- 2011 -0860
Project # JS- 2011- 001417
Est. Cost: $14300.00
Fee: $70.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JESSE MONTGOMERY 077410
Lot Size(sg ft.): 8494.20 Owner: HOGAN AMY
Zoning: URA(100) Applicant. JESSE MONTGOMERY
AT: 6 STOWELL ST
Applicant Address: Phone: Insurance:
P O BOX 329 (413) 585 -8482
LEEDSMA01053 ISSUED ON :412812011 0:00:00
TO PERFORM THE FOLLOWING WORK.- REPLACE ROOF & SIDING
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 4/28/20110:00 :00 $70.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
City of Northampton M
j�
Building Department
212 Main Street
If 4ti4 �, Room 100
�I Northampton, MA 01060
p� ne 13- 587 -1240 Fax 413- 587 -1272 ,
E
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 Unit
d f OS��' Zone Overlay District
Elm St. District CRDistrict
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
c 6 � S4. Legt
Name rint f Current ailin Add
Telephone
Signature
2.2 Autho rize ent:
e se /'1 -1 oar `i a oa.k S�- pwere i"4q. D (C b a
Name (Print) Current Mailing Address:
Signatu Telephone
CTIO STIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
m leted by ermit applicant
1. Building /[I��j (a) Building Permit Fee
2. Electrical ( (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building' Permit F I ee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = 0 + 2 + 3 + + 5) �. C.'C" Check Number
This Section For Official Use Onl
Date
Building Permit Number. sued:
Eignature:
Building Commissioner /Inspector of Buildings Date
r
, ^
' w
` 1
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
Setbacks Front
Rear L--j
Building Height
Bldg. Square Footage 01"o
Open Space Footage %
(Lot area minus bldg & paved
# of Parking Spaces
(volume & Location)
A. Has a Special Permt/Variance/R been issued for/onde site?
�� KNOW NO «�� DON7 KNO ��" YES v� ��
�
IF YES, da1eismed:
IF YES: Was the permit recorded atthe n*oeeos
0 NO DON7 KNOW YES
IF YES: enter Book Document #
�� ��
B. Does the �tecontain a brook, body of water orwetlands? NO ��/ DON7 KNOW �_� YES �~�
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs to bembta obtained »~~� Obtained «~-* Date Issued:
' v�� ' ' '
C. Do any signs exist on the property? YES 0 NO �
|
|F YES, describe size, type and locat _J
D. Are there any proposed changes toor additions of signs intended for the property 7 YES K l NO 0
IF YES, describe size, type and locatio
E. Will the construction activity disturb (clearing, gradingeexation, nra||i ng)uvar1aon u nr'opo�orocommnnpmn
thatwi||di�urbower1o� �� e? YE8� � NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks (Q SidingXj Other [E )
Brief Descnpqq of roposed n �„
Work: ep K[-rs t ca nol ,src� �a,
Alteration of existing bedroom Yes 11" No Adding new bedroom Yes V
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa if 404 �racitli ioi x�stlnu F>�otisina o r liY t `the fattaw c
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 Ta - OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING'' PERMIT
as Owner of the subject
property J
hereby au onze J $� I 1rJ►Z' Y►�dr
to act y ehalf 1 all rs relative to wdWauthon - M by this building permit application.
A r
atdFe of ner ate
�e r as Owner /Authorized
Agent hereby declate that the state information on the foregoinl application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
P 'n ajo
e r
ig atu :ent
Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holde (777 L l 1 0
License Number
ka 0 -J< /tw Of (624 ///
Address Expiratiofi Da
Telephone
.12 ais er d tl r rd ltri rovemett�ot star � ..T ea &a Iff" ,_ w Not Applicable ❑
134 a71-4
Company Name Registration Number
a Oa t>; Sa-. !0 i� 1 5 J
Address �t J �^ Q Expiration Date
1 . of 06 C2 Telephone p 1'(e
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...... ❑
In-
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 Massachusetts
Department of Industrial Accidents -
Office of Investigations
600 Washington Street
Boston, MA 02111
,. www.mass govItha
-Workers' Compensation Insurance Affidavit: Builders/ ContractorslElectricians /PIumb.ers
Applicant Information Please Print Legibl
Name ( Business /OrganiaanowIndividuai):
Address:
City /StateJZip: Phone. #:
Are you an employer ?.Check the appropriate box: Type of project (required):.
7. Remodeling
4.- [] I am a general contractor and I
1,�J I am a employer with -1 6. E] New constr=tion
9 'employees (full and/or part tim listed on the sheet. e).* have hired the sub - contractors
2.. El I am a sole proprietor or partner-
ship' and Dave m. e-7loyees Thu sesub- contractors lave. .8. r Demolition
working for me many capacity. emloyees and have workers' qa =Q Boil addition
[NO workers comp msttrance -comp ' #_..
required] 5. []. We are a corporation and its 10.0 Electrical repairs or additions
officers havexercised their 11.0 Plbing repairs or additions
3. I am a homeowner doing all work r . .
myself [No workers' comp. right of exemption per MGL 12.yRoof repairs
insurance required] t c. 152, §1(4), and we have no 13.❑ Other
employees. [No workers'
comp insuranc requirfAj.
"Any applicant that checks box #1 tmrst.also fill out the section below showing theirworkers '. compensation policy information
t Homeowners who submit this affidavit:indicnting they are domg all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attac an additional sheet showing the name of the subcontractors and state wheth= or not those have
employees. If the sub - contractors have employees, they must provide dm workers' comp. policy number.
f am 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. #: OiOCf (� 7 trL (0 Expiration Date: 3 t :�
l� S C• sra& L eek / . 0 IOS3
Job Site Address: (5 �J'�'�"C- n3 gyp=
Attach a copy of the workers' compensation policy declaration pae the p9licy number. and expiration date).
Failure to secure coverage. as require d'bri&Y Section'25A'ofMGL c. 15Z can lead to the imposition of'ci penalties of a
fine tip to $1500.00 and/or one -year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a 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
Investigatioiis of the DIA for insurance`coveraeewerifria6oa
Ydo hereby certify under t aloes ofpe*y that the information provided uhays_issrue ancLcorrect__
Signature: am- I i
Phone #• �t t 3 `- 4? `t 82 _
Official use only. Do not write in this dreg to be completed by city or fown'officaL
City or Town: PermitUcense #
Issuing Authority (circle ane):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Xnspector 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 homeowner 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 backrdl),
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 insuections 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
permits 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 /resident'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