12-002 fin
BP- 2010 -0192
GIs #: COMMONWEALTH OF MASSACHUSETTS
My -- ,i2 4 o t2 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category BUILDING PERMIT
Permit # BP- 2010 -0192
Proiect # JS- 2010 - 000234
Est. Cost: $9500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 84506.40 Owner: CHAMBERS ROBERT A & SUZANNE F
Zoning: RR(100) //WSP Applicant: CHAMBERS ROBERT A & SUZANNE F
AT. 211 NORTH FARMS RD
Applicant Address: Phone: Insurance:
211 NORTH FARMS RD
FLORENCEMA01062 ISSUED ON :812112009 0:00:00
TO PERFORM THE FOLLOWING WORK.- REPLACE & ENLARGE EXISTING DECK
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 8/21/2009 0:00:00 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -0192°
APPLICANT /CONTACT PERSON CHAMBERS ROBERT A & SUZANNE F
ADDRESS /PHONE 211 NORTH FARMS RD FLORENCE
PROPERTY LOCATION 211 NORTH FARMS RD
MAP 12 PARCEL 002 001 ZONE RRO00) //WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 0 1 7V 016-
Typeof Construction: REPLACE & ENLARGE EXISTING DECK
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
INFO ATION 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
� /ZC
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.
IV
O A 4
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p etty of Northampton Etu�e 4
SRI
Building Department Cu��tltie�
212 Main Street S1ii�et opi�
tAr�raitab y st
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Room 100 ��u�
`3 Northampton, MA 01060
�U phone 413-07 -120 Fax 413 - 587 -1272 M tte s Yy`
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I,- SITE INFORMATION
This section to be completed by office
1.1 Property Address
MaR Lot Unit
�dY' Ge JA it e� C �� Z Zone Overlay District
Elm St. District CB District
SECTION «r.2 - PROPERTY' OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: �'
�c1 7 G `t -2-1 �_���_.�1�
Name (Prin Current Mailing Address:
SAY S3 "7r�
Telephone
Signatur
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
S'ECTION;3 - CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building o (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) l/U Check Number -
This Section F.or OfEcial Use'bnl
Date
Building Permit Number. Issued:
Signature:
Buflding Comrriissionerflnspectorof 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 /I ow �S
--- .., y
Frontage mm 0 __ .W__.. _...- __,....___. _ _._, ,_ . ._ __ --
Setbacks Front
Side L: .2 2 R L w7 Z
Rear �S
Building Height
Bldg. Square Footage
Open Space Footage _ _ % -
(Lot area minus bldg & paved'
p arkin g)
# of Parking Spaces m -� -•` ''
Fill:
volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 _ DONT KNOW YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
N0 0 DONT KNOW YES
IF YES: enter Book Pagel and /or Document # - V
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES
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: `ire there any proposed c angel o or act�i ions of - signs intended -fog the 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 it part of a common plan
that will disturb over 1 acre? YES 0 NO ;y
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
owl
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 [O]
Brief Descri 'on of Proposed
Work: le 66
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa lf= New;House anti or:addltion °to existlna dousing co Met :4,h "' ott�inring:
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 o 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
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.
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 Nam
Signa re o ner /Agent D e
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder A4 a Z / e ll I
License Number
2 _ �2 /2� ,�►�
Address Expiration D e
Sign re Telephone
g Regis €ered Ffome- lnio�emen #.Gontrac#isr . . S 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...... ❑
'k ki'M
-
The-current-exemption for. "homeo� tiers" was extended to inclpde_ occupie wellines 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 dweIIing, 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 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 trances;` a e and — ml"Zl - id�6fMassaehusettsGeneral- Laws -An. notated.
Homeowner Signature'
The Commonwealth of Massachusetts
Department oflndustrial Accidents '
Office oflnvestigations
600 Washington Street
Boston, AL4 02111
www.mass gov /dr'a
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers
Applicant Information / Please Print Legibly
Name ( Business /Organization/Individuai): �� �? ,M d 12,1 (V
Address:
City /State /Zip: 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
employees (full and/or part-time).*
have hired the sub- contractors 6• [] New construction
2. (� I am a sole proprietor or partner- listed on the attached sheet. 7. [3 Remodeling
V ship and have no loyees These sub - contractors have. .8. [1 Demolition
working for me in any capacity employees and have workers'
[No workers' comp: insurance - omp. ' 9. Butt addition
C II3S E
required;] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am- a- homeowner doing-afl-werk- - - - - -- - ---Q fi e have xer eis .. fLEIglumbingrepairs or additions
myself. [No workers' comp. right of exemptiofi per MGL 12. ❑Roof repairs
insurance required.] t c; 152, § 1(4), and we have no
employees. [No workers' 13.90ther
cow. insurance requised.j.
'Any applicant that checks box #1 must also fin 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 contractors 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 their workers' comp. policy number.
lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
in
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 0 . f MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one - imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a e
of up to $250.00 a day against the violator; Tie advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereb certi er
___y f3' pares and penalties afperjury that the iu :forinatzon proveded.above_is.tr..ue_an&. orrecL__
�. Si lure:.
:?ate: (�
Phone #:
Official use only. Ilo not write in this -area, to be completed y city or town ociaL
City or Town: PermitUcense #
Issuing Authority (circle one):
- I: -Board of Health 2. Building Department 3. City/Town 4. Electrical Inspector S. Plumbing Ins getor____ 6. Other r
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
xegulation The inspection nroc reauir�s that the building department be calle to
inspect work at various stages, which include foundation /footings (before backfil[),
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
--------- - - - - - pits-- in_- conjunction_to_the-buildffi permitissued,. -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
J I, understand the above.
(Hom owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
--
Address of work
Iocation
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211 NORTH FARMS RD BP-2010 -0192
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc 12 - 002 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0192
Project # JS- 2010 - 000234
Est. Cost: $9500.00
Fee: $50.00 PERMISSION IS HER_ EBY GRANTED TO:
Const. Class: Contractor: License:
Use Grouy: Homeowner as Contractor
L ot Size(sq. ft.): 84506.40 Owner: CHAMBERS ROBERT A & SUZANNE F
Zoning: RR(100) / /WSY C1-1A " v LQE; ^S 'L y °,T ^. °. S—'U AR P
AT: 211 NORTH FARMS RD
Applicant Address: Phone: Insurance:
211 NORTH FARMS RD
FLORENCEMA01062 ISSUED ON. 812112009 0 :00 :00
TO PERFORM THE FOLLOWING WORK .- REPLACE & ENLARGE. EXISTING DECK
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: /1OL �k
trS
Rough: Rough: House # Foundation: (5 •b 9
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOL ION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy � Signature:
FeeType: Date v Paid: Amount:
Building 8/21/2009 0:00:00 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
211 NORTH FARMS RD BP- 2008 -0570
GIs #: COMMONWEALTH OF MASSACHUSETTS
1vlap:Block: 12 - 002 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Peii „it: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category BUILDING PERMIT
Permit BP- 2008 -0570
Projec # JS- 2008 - 000862
Li Co st $2000.00
F S 50.0 0 PERMISSION IS HE REBY GRANTED TO:
Co C lass: Contractor: License:
Grou Homeowner as Contractor
Lot Size(sg. ft.): 37026.00 Owner: CHAMB I ;UBE RT A & SUZANNE F
Zonate :,RR Applicant: CHAiViB';RS ROBERT A & SUZ F
. 21 NORTH FARMS R
Applicant Aii res3:: T'Yteme: insi..rance:
211 NORTH FARMS RD
FLORENCEMA01062 ISSUED ON. 12/6/2007 0:00 :00
TO PERFORM TITE FOLLO! PING WORK ENLARGE & UPGRADE BATHROOM
POST T HIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of 1'lunibing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
n d
# 6 �” �' g f1f�h -'K�'I J Footings:
Rough � � � ou h: 1 Rouse # Foundation:
/ Driveway Final:
Final: 7! / 111eF 9/t1
Rough Frame: B r O t 1 103 0�r �j N l 5
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation: ot< 01
j tqlp ii r
C
Smoke: i±inai: nt,K 11 12z' p � V -
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
C fica or Occupancy Signature
t�ee ''ype: ate Paid: Amount:
Building 12/6/2007 0:00:00 $50.003778
212 Main Street, Phone (4' 3) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo