12C-035 o� UtiILT BP-2010-0960
GIs #: COMMONWEALTH OF MASSACHUSETTS
:Bloc iZC j o3 5, 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 -0960
Project # JS- 2010- 001422
Est. Cost: $3314.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): 14418.36 Owner: COYNE MICHAEL A & PATRICIA A
Zoning: URA(100)//RI/WSP Applicant HOME DEPOT AT HOME SERVICES
AT. 39 BURNCOLT RD
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401
Workers Compensation
WORCESTERMA01607 ISSUED ON :412912010 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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 4/29/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
4
,
City of Northampton
Building Department
212 Main Street
Room 100
Nort hampton, MA 01060
phone 413 -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
Map; . Lot Unit
e w
Zane; Overlay District
E(rn 5t bistrlct , GB District
SECTION '2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) �,� Current Mailing �p dress:
Q �� V 1l rG
a >Z Telephone
Signature
2.2 Authoj4zed A ent:
Name (Prin P Current ailing Address:
Signature Telephone
SECTION 3 - 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) 4 — Check Number j
This Section For Officlal Use Onl
Building Permit Number: Date
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 Department
Lot Size
Frontage
Setbacks Front
Side L= R: L: ---- -- R: ._..__..._
Rear �. --•-� z �
Building Height ---- r
Bldg. Square Footage 011'0 I
Open Space Footage_ �� %
(Lot area minus bldg & paved
par
# of Parking Spaces - - -•f — - -?
Fill:
volume &Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES Q
IF YES, date issued-4
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES Q
IF YES: enter Book and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q 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 ® 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 Q
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 Q
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 Win s Alterations) El Roofing 1:1 Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [a
Brief Description of Propose`
Work: a'
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
�a..lfieE>atu �dc tStit� Cf�$t
wis
im
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 !- Td BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES F.OR BUILDING PERMIT'.
�r 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.
L l
Signature of Owner Date 1
k r as Owner /Authorized
Agent hereby declare that the statements and i formation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pain an enalties erjury.
v
Print Nam
Signature of ne / ent Date
SECTION 8 - CONSTRUCTION 'SERVICES
8.1 Licensed Construction S ervisor.: Not Applicable ❑
Name of License Holder 6- )- b
License Number
D 4441 P
Add re s Expiration Dat
Sig to Telephone
Not Applicable ❑
O
Company Name Registration Numbe
Address � / _,� Expiration Date
'[ 1 �1/�� Telephon C�
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)),,
Workers Compensation Insurance affidavit st be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildi permit.
Signed Affidavit Attached Yes....... No...... ❑
f
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 hom eowner.
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 and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
T
/ u
The Commonwealth of Massachusetts
Department of Industrial Accidents -
U Office of Investigations
600 Washington Street
Boston , MA 02111
ww mass gov /dia
-Workers' Compensation Insurance Affidavit:.Builders/ Contractors /Electricians/Plumbers
Applicant Information Ple Pri LegibIV
Name ( Business /Orgm iiation/individual):
Address:
City /State/Zip: Phone. #:
Fyou an employer ?.Check the appropriate box: -Type of project (required):_
I am a employer with 4.. I am a general contractor and I
have hired the sub - contractors 6. C] New construction
employees (fall and/or part time).*
2..Q I am a sole proprietor or partner- listed onthe;attached sheet. . C] Renzodehng
These sub - contractors have .8. ❑ Demolition
. ship and have no employees .
wor for me i n an Plow and 3zaye wotl ers'
king y capacity. -- -- 9 Q_Buldtag alition
workers'' comp- 1ffiI3Ia73eC -. CQIDp• m�marce #_ _ -.
required ]
5. We are a corporation and its 10 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have Exercised their 11. C] Plumbing repairs or additions
myself: [No workers' comp. right of exemption per MGL 12.C].Roof repairs
insurance re cd t c. 152, § 1(4), and we have no -
o workers' 13.El Other
employees. (N
comp. insurance required.).
*Any app licant -that checks box ill must,aiso fill out the section below.showing tbcirT!orkcrs'.=np=sa1ion policy infarnmtion
t Homeowners who submit this affidavit.indipring they are doing all work and then hire outside Contractors trust submit anew allidavit indicating such
:Contractors that check this box must attached an additional shed showing the name of the subcontractors and statcwbed=,ornot those entities have
employees. If the sub-contractors have employees, they must provide their workers' comp..poHcy 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
Policy # of Self -ins. Lic. #: Expiration Date:
Job Site Address: City/Stafel7sp:
Attach a copy of the workers'" compensation policy declaration page (showing the policy number. and ezPiratton date).
Failzn e. to secure coverage. as required isndei Seatioii 25A'of1GI fL'c. T32 Duff lead "to �e imposition of` penalties of a
fine up to $1,500.00 and/or one -Year imprisonment as well as civil penalties is the form of ;t STOP WORK ORD£R and a fie
of up to $250.00 a -day against the violator. Be advised'that a copy of this statement may be forwarded to the O.Mce Of
Investigations of the bIA for insurance coverage verification.
I do Jiec4 Oy -pen, under the pains penalties ofperju. that the vZ&dlib00 strue ad evrrect -_:__
Signature Date
Phone # '
Of zdd use only. Do not write in this area, to he completed by city or town "official
City or Town: _ P6rmft/License #
Issuing Authority (circle one):
J. 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, 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 /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued tome.
Date
Address of work
location
Said, PumisAed atad Ins"ad by.
Y3raaek Won*. Denim . riate: � ' THD At Home $CtYibea,.TgC
d/Wa 7U Fiormo MpmAt Horne Services
345A�.[RnwOW Sweet, Unit 2, Wor0esW, MA 01607
13ranth Number 31 Toll Prey (800) 657 -5182: FM (Sm3) 756.8823
J;adaal•m (H7 269&460; ME Liv N C 0240, RI Coat Lio# 16427
CC X•,} #isesu MA 1<1~ t Cpnuacror ties. A ) 2639"3
hwWbfisn-Adi�ew LA
pt)c state zip
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(If d0wwt howbotsigafift Addtv*O City sum zip, (c,
1>rHSrir Ad�eas (ta sts>aaoe ptojcclt'oorormuaicmioas ead:IlestHt I�po�Cttpdtstma): _ _- -
Cj 1 DO. MOT wish Rom Dew
U pnapertq, agrees to buy,
�Q TH _ L- ("� tfip'oWmeta of the ; 4ocated itr.tfieaboyc irmtailadam address,
and t HD AHO e'Sbrvr�, In, (" Dw Herne t") agrees to fiunS* deliver and arrange fm the installation (`Ynstaftdm ") of
911. matcrials dt�tsibed oq t14C below Drat on the ielareAOed Swx Sliegt(a).•all ftf which era +ucotporaueat into this Contract by this
re aloft with any appli -WO $rase SnpPlemaat•a.d Pa Spw. Y:tnMClHed ]Hereto and ariy (`hatige Orders (4ollecavely.
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Brien 'aifetl�e'a�lilcCaetr*atAaenmit. ':
Ltitstnnter.aBibes:0ast, .1tP ; geudop14*0p of tbc e3�i.� ill . CWomer w ezxute a Completion C Mficato
(one for each dt as 46ited b3' in lbdiv $pax 9'.SCrt) and attq bilanae dw. At sppiicahlo, cash C�atonw tinder this
con±rxc. -t agree m hei4intJy mi �w�a►Yy obl;d ama.Yunld ti�reuuiler. ;
The Home D" xee-.w the itgbt to issue a Ownp Order or tetnoWAW *6 C,ontraer, or say iu&vidjW PsOdmt(6) included herein, At
its dish it The How Yxpot'or • suthorined t,ervlae pxiov7tder datermin� .that it Pon= perfb m its obiiga6oas doe to it structtn d
problem with the humt; emvitn mil• Ba7brds•suiCtr 4a OW. or lead '.p6nt, other safety concerns, pricipe errors or because
worst mQoired to o Mp)Map " job iiras not, includw iii 411 � ... r
Tfie PLyament'Stmmpry. - o '. . +""R.�'' `i 'wluded as pert of ibis Contract sane forth the total
Contract amount and Paynrara eegt�ed fciir t46 �pKtsirs Hind l6 ied rct (as applicable).
YOU are eatltled to'a '' of tbili Co0tlatt alt t�He.f$ghp > '" 16o a Completion Cer�te (notes
there Is am Caatlara�arattaae for �d lP roditrtt 646 diedFk Spec Shdees) before work om that Product
is complete.
In the evelat of twedua foe of tkp Gtastrttct, CsA mer'agcm to pay 7U li OM the costs of tmgteaiais, sabot, "Pew
an d se Tim peevided by ThO SOW Dept or �4O#wti%id $txvice Pro�viiar t?ie d�xte at te+�naRiety ppYrta aioy other
aetonoats ad f0aih to thi6 A rt or wed'mder• law. THE HOMMTOT MAY Vf�T'Jt'fiHOI.,D AMOt]NTS
OWW TO TM HOMR MFOT PUOM ME D =A 434 01'�3t PA'YMENT'S IN
MAE:, WrrHOITT
Ltb1T'riNG THE HOME DEPOT'S 4'1fMR $EMEO>�S'FM 1XCO MY OP SUCH AMOUNTS.
&%gjjft% mad A Customer agrees and tmda -Asada "Ada Agrbwxmt Is the ctxite agreement belwam Customer
saw 7W moue DOW with reseal ta•the ptoducf8 smd.Ittstsllasi set:otcas and supetseties all prior discussions and agreements, either
Orel or wrltlen, to said Pmdect4•amd•Instdtsai6m. TW Aipmomortt camaot be aasagaW or amended except by a writing signed
by Cu6Wmor amdRome Depot; Owoma aekoocvled & sad agrees that• G'ostontea has rend. UrAerstws. voluntarily see" Li
terms Of And has received a copy Vf Yids Apmmem.
A let flLacc s 4'• d V—/0 3C r�
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x Telepboue No.
Cusrotoer's Sigmatore lisle Sales Corm Draw D cmw me.
CANGff ATION CXTSTQMM MAY CANCEL T'H1,9. (as Hppliaabk)
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