12C-046 BP- 2010 -0273
GIs #: COMMONWEALTH OF MASSACHUSETTS
t2C •1346 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 -0273
Project # JS- 2010- 000350
Est. Cost: $2600.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 13982.76 Owner: SMITH BRENDAN
zoninp-: URA(100)HRI /WSP Applicant. SMITH BRENDAN
AT. 38 LEENO TERR
Applicant Address: Phone: Insurance:
38 LEENO TERR (508) 572 -4408 O
FLORENCEMA01062 ISSUED ON :911012009 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 9/10/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
- _
-- �� gyp, ��3�Se�et11+
�itr of Northampton
-, i Buildin Department
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212 Main Street 'ital
Se rw'
SEP - S 2009 Room 100 y 4
►�Toitlnampton, MA 01060 wfl a ��
- ate -413-5 7 -1240 Fax 413- 587 -1272
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APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
ECTION 1 - SITE INFORMATION
1.1 Property Address
This section to be completed by office
Ltte �e7-9A Map Lot
Unit
1✓(.i� IZG� C E fV1A a ilia Z Zone Overlay District
Elrtt$t'District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of -Record
P ' -
Na me -
( Current Mailing Address: �+
0�
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 1- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building ®Lit, .J (a) Building Permit Fee
2. Electrical (6) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = 0 + 2 + 3 + + 5) Check Number
This Section For Official Use'Onl
Building Permit Number. Date Issued:
Signature:
Building .. C omrni ss i o n er/Inspector of Buildings Date
i
i
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
r.
Lot Size
Frontage
Setbacks Front ` m
Side L: R :.,,,- - L __x_. _. R
Rear
Building Height
Bldg. Square Footage i.. %
Open Space Footage _.__, _,..,., % 7 1 -• --
(Lot area minus bldg & paved
p arkin g )
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 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
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 - - --
__ .....__ . ... .. ..... ... .......... . . . ... ..... .............. ......_.
- - Are - t ere any proposed changes to or a l ions of�5i ns ntended 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 NO 0
IF YES, then a Northampton Storm Water Permit from the DPW is required.
J
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors E] I N
Ac ssory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [❑] Other [O]
Brief Descri tion of Proposed t
Work: 19 O Lb I;k\\ C � 1 %1 ems✓ IT lci F.--j'J 7 SN) t•,C .t_ES
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative . Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa. ff..Neuu house. atld or:aticlrtton to ez sf tnq t ouslnq ct3it plete h
q :
a. 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 st ories?
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 - QWNER AUTHORIZATION - TO BE COMPLETED WNEN
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, T)Ytt-J tT N 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 u nder the pains and penalties of perjury.
y�;��i�
Pnn Na
Signature o ner /Agent Date
s
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9... Reg "stered;fiQme;;linp�o�ditaesi Gnntracto ,. ,... k= :' 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...... ❑
n y.
.The_current exemption for.``homeowners "_wr extended to include _O wner -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
N o ampton r ma ce �VTU - - ral- Laws.Annotated.
Homeowner Signature
1
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
_ a 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Bui lders/ Contractors /Etectricians/Piumb.ers
Applicant Information ____ Please Print LeQ-ibly
Name ( Business /Organization/Individual):
Address:
City /State/Zip: Phone. #:
Are you an employer? Check the appropriate box: ..T ype of project (required):
1. ❑ I am a employer with 4• [] I am a general contractor and I 6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
2" F I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have ?+o. emp loyees These sub - contactors have g ❑ Demolition
working ' for me in any capacity. employees and have workers' 9 Buildn g addition
[No workers' comp. insuran com msuiance
required.] 5" ❑ We are a corporation and its 10 "❑ Electrical repairs or additions
3. I arm -a homeo-waer dei$g�ll wotk __ __. - - -- _ . - - -9 ce�slia xe z ised hoir --I LaRlumbing 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 twist 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 them. hire outside contractors must submit a new affidavit indicating such.
zContractors that check this box must attached an additional sheet showing the na= of the sub= contractors and state whether or not those entities have
e mploy ee s. If the sub-contract . have employees; they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation hisurancefor my employees Below is the policy and job site
f
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 23A of 1vIGL 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 fine
of up to $250.00 a day against the violator. 13e advised that a copy of this statement maybe forwarded to the Office of
Investizations of the DIA. for insurance coverage verification.
do ereb}? _certify under the p and penalties of perjury that the provi rled above'ue an�rLcvrrecG .__ _ _ ..__ i afore: _ te:
Phone 0: 3 Of
riicial use only. Do not write iin Elio - area; to be comp red ly city or town official
.City or Town: Per-mitUcense #_
Issuing Authority (circle one):
I. Board of Health 2. Building. Department 3. City/Town Clerk 4. Electri cal Inf ector 5. Plumbins Inspector
6. Other
Contact Person: Phone #:
y M
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_cfNorthampton _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
regulation The ins ection process requires that the building department be call to
inspect work at various stages, which include foundation /footings (before backfilI),
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
- -- ---- - - - - -- perms- in- cen}unctionto_ 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
/ Zip DIN P 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 me.
n to
Address of work
location ' L sc) i r 121 e
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