12C-033 BP-2010-0164
GIs #: COMMONWEALTH OF MASSACHUSETTS
v labck: i 2C = CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate BUILDING PERMIT
Permit # BP- 2010 -0164
Project # JS- 2010- 000203
Est. Cost: $8200.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CYRUS NEWMAN 064690
Lot Size(sq. ft.): 14984.64 Owner: GAZZILLO ROBERT N & CAROLYN R
Zoning: URA(100) / /RI/WSP Applicant: CYRUS NEWMAN
AT: 23 BURNCOLT RD
Applicant Address: Phone: Insurance:
697 Bridge Road (413 5) 86 -1093 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON :811112009 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 8/11/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
*W-
City of Northamptont� h g
R
Building Department
212 Main Street
u�t E a
Room 100 ����
Northampton, MA 01060 Twd, t i to ra �a z
phone 413- 587 -1240 Fax 413- 587 -1272 PIPiarrs s
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TW �' IL/t D E N0
SECTION 1 SITE INFORMATION- AU
This section to be complete
1.1 Property Address .
o
Map -Lot .� Unit
Zone Overlay District_ vS
F (G v1 C
"Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
- A-K-6 J.4) (�C? ZZ I _'125 /_5 LJ -1Z A)
Name (Print) Current Mailing Address:
FIri✓l`Lr1C
Telephone
Signature
2.2 Authorized A nt:
�! m
Name( rin Current Mailing Ad ress:
- 5 " 7b Q
Signature Telephone
SECTIO - !ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost- (Dollars) -to -be Official Use Only
completed by ermit applicant
1. Building (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
77 ( ) Check Number
This Section For Official'Use Onl
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
Section 4. #ZONING nf ormation 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
LG S t ize .�....�P
Frontage
Setbacks Front
Side L R : L M R ._ _... A _• _ _.._....
Rear _._
Building Height _ ...
Bldg. Square Footage "`
Open Space Footage
(Lot area minus bldg & paved i y �
p arkin g)
# of Parking Spaces - .. .... ...
Fill: _ m_. ��P�
volume &Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 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 0 NO 0
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 0
IF YES, describe size, type and location.
E. :.'i!! 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 0
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 [ Addition Replacement Windows [ Alteration(s) Q Roofing El
Or Doors
Acce33ory Bidg. n Demolition n l VW Sign.3 [^1 Dz�:k3 (� S iding [ ^u ] Other [ut
Brief Description of Proposed /
Work: ?�!Z ,L c� i ✓I> T' r<
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa: :lf �[ew =house anar adifton tt%exicciaus�nc;irr�fetetii F[tornia
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
1 . 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 pay s and penalties of perjury.
Print Name
Signature of Own Agent Date
l
i
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder �1j C
License Number
(oq - : ) r r1
Address Expira - {ion Date
Si a e Telephone '
. Rectisteeecll -lame�lmnrave'meriCal>Etrafor Not Applicable ❑
Company Name Registration Number
0-4 rJc 2cI 512-1 bn
Address Expir tion Mate
s
fi4f� Telephone
SECTION 10- WORKERS' COMPENSATION INSUR ANCE 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...... ❑
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 -o€ the -work - for- whidt- this- pemiit-i- s- i- ssued.- - - - - -- -- __ ._ _ -
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 bf In vestigations
-- � 600 Washington Street
Boston, MA 02111
www.mass.gov /dig
Workers' Compensation Insurance Affidavit: Bl iilders/ Contractors /Electricians/PIumbers
Applicant Information Please Print Legibly
Name (Business /Organization/IndMdual): 1 e u
Address: �-
City /State /Zip: ' It, Ph #:
F an employer? Check the appropriate box: Type of project (required):
a employer with � 4. ❑. I am a general contractor and I
loyees (full and/or part- time). * have hired the sub - contractors 6. ❑New construction
a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
and have no employees These sub - contractors have g. ❑ Demolition
ing for me in any capacity. employees and have workers' 9. Building addition
workers' comp. insurance comp. insurance.T
required.] 5. ❑ We are a corporation and its 10. F Electrical repairs or additions
3.0 I am a homeowner-doing- aH -wark - - - -- -- -- officers have exer their _ 11_ ❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs .
insurance 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 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
employee`s. If the sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ��(�(� __7 .
Policy # or Self -ins. Lic. #: '� }�ZZ�`"1, Expiration Date: 1'4' (')
Job Site Address: City/State/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 $ and /or one- yearimprisonment- -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 may be forwarded to the Office of
Investigations of the DI A for insurance coverage verification.
I do hereby certify under th pains andpenalties ofperjury that the information provided above is true and correct.
K Signature: Date l O `;
Phone #:
LOther only. Do not write in this area, to be completed by city or town official
n: Permit/License #
thority (circle one):
3. City/Town Clerk- _4 - F-lac rson: Phone #:
i
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
7as f Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
er construction supervisor. The state defines "Homeowner" as, " Person(s)
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 wor various ages, which i�hrd founc}anon/footiugs -( before baEl{f�fl),
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 wor cari -e insiieefed° ,...
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 w l 611 to sc - &dule ra��equired GuiTding inspections necessary for the building permit
issued to me.
Date
Address of work
location
Page No. of Pages
P ro p o sal
NEWMAN'S CONSTRUCTION
697 Bridge Rd.
Northampton, MA 01060 1022
413- 586 -1093
PROPOSAL SUBMITTED TO PHONE DATE
A 19 h GI F 71 10 '7
STREET JOB NAME
C- :72
CITY. STA E and P CODE JOB LOCATION
A c�) o Lax
ARCHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for:
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We Pr oPOSP hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
f ' CCU _.
' dollars ($ ),
Pay ent to zas follows:
14 e? i C3 ��i1C
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders, and will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Note: This pro s I maybe
Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not ac ted within days.
7a�ndco!nclitions ptaurr of P ro p osal — The above prices, specifications
are satisfactory and are hereby accepted. You are authorized Signature
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: Signature