42-012 ;0 FARMS RD <<f � BP-2011-0132
GIs #: COMMONWEALTH OF MASSACHUSETTS
' - Iock: 42 - 012 CITY OF NORTHAMPTON
Lot: -001 y PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building A DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: B UILDING PERMIT
Permit # BP-2011-0132
Project # JS- 2011- 000223
Est. Cost: $635.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 34978.68 Owner: DUTEAU JAMES & KATHLEEN
Zoning: SR(100)//WSP II Applicant DUTEAU JAMES & KATHLEEN
AT. 288 WEST FARMS RD
Applicant Address: Phone: Insurance:
288 WEST FARMS RD (413) 585 -0625 O
FLORENCEMA01062 ISSUED ON. 812412010 0:00:00
TO PERFORM THE FOLLOWING WORK.- CONSTRUCT 8 X 12 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 8/24/2010 0:00:00 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP- 2011 -0132
APPLICANT /CONTACT PERSON DUTEAU JAMES & KATHLEEN
ADDRESS/PHONE 288 WEST FARMS RD FLORENCE (413) 585 -0625
1 (
PROPERTY LOCATION 288 WEST FARMS RD
MAP 42 PARCEL 012 001 ZONE SR(100) //WSP II
Q
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
O f—
Fee Paid
T_ypeof Construction:_ CONSTRUCT 8 X 12 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE F QLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
F 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
cJ7 k 2,? _ 1 a 0
Signature of Building Mcial 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.
City of Northampton°
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413 - 587 -1240 Fax 413 -587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE TWO FANIiCY DWECCiFiG — � '
SECTION '1 -SITE INFORMATION
1.1 Property Address
This section to be completed by office
�,�. 131 Lot Unit
A4 � /j bane overlay Dstr�et
Sim $t `Dlstiict CMDistrict
SECTION 2 -.PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
GEC
Name (Print) Current Mailing Addres
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building p O (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing BuildingPermit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= 0 +2+3+4+5) Check Number
This Section For Official Use Onl
Date
Building Permit Number: 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 1
Frontage
Setbacks Front i
Side L: L_____.'s R: _......__._' L: R: [ ;}
�- Rear
Building Height
Bldg. Square Footage % --
Open Space Footage %
(Lot area minus bldg & paved ' �v
par
# 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 Q
IF YES, date issued:j
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I Pag and /or Document #�
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES Q
'. " lk
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
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
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTIONS- DESCRIPTION OF PROPOSED WORK (check all applicablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing El
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [ Siding [1:3] Other Co [
Brief Description of Proposed
Work: !r (�
Alteration of existing bedroom Yes No Adding w bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
s a r Ne fi�lt Set- i . dd
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 Bl COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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
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 Name
Signature of Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
11Reistedloedr�`rlreiYerit lad "i*ior , M 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...... ❑
. A
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 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 s nd State of Massachusetts General Laws Annotated.
r
1
Homeowner Signature
T
The Commonwealth ofllTassachusetts
Department oflndustrial Accidents .
Office of Investigations
600 Washington Street
` Boston, MA 02111
www.mass gov /dia
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers
Applicant Information Please Print L �'blv
Name ( Business /Organimnon/individual):.
Address:
City /StatelZ P: A lf. 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.. 0 I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and Have no: =Tloyees These sub - contractors have. .8. F Demolition
working worleers ' for me m any capacity. =Tjoyees and have worersk' 9
Comp. mQrrT.171(`0_ #.. Q B aCldltiOn
co mp. Ism anCe
required] 5. EJ Were a corporation and its 10.0 Electrical repairs or additions
3. I am a homeowner doing all work haveGercised their work 11. ❑Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12: Roof repairs _
insuran required.] t c. 152, §1(4), and we have no
employees. [No workers'- 13. Other 46GK
comp. insmizace required}.
•Any appfic;t That checla box #1 ffirst.nlso fiII out the section below showing dmir workcs' c w-ns -dm poficy information:
r Homeowaers who submit this afdavit:indicanng they are doing an work and then hire outside contractors must submit a new affidavit indicating such:
lcontsactors that check this box must. attached an additional shed showing the name of the sub = contractors and state vket icr or not those entities have
employees. If the subcontractors have employees, they must provide their workers' comp. policy number.
tam an employer that is providing workers' compensation insurance for. my employees Below is the policy gnd job site
information.
Insurance Company Name: .
Policy # or Self ins. Lic. #: Expiration Date:
Job Site Address:
City/State/zip.
Attach a copy of the workers' compensation policy declaration pa e'(showing the policy number and expiration date).
Failure. to secure covera as re gee - d ini&Y Secti on 25A ofMGL ii 152' sari lead to me iposrtion of ciinm�I penalties of a
fine tip to $1,500.00 and/or one- year 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 maybe forwarded to t O ffice of
Tnvestrsat<ons of the DIA for insurance coverage verification. �`` -
I do hereby ee under the pains pen s of perjury that - the m ormation pro av : LT trf[P_ arr
Si tare: ate. _
44 -
Phone #:
OffI dl use only. Do not write in this area fo be completed by or town offu raL
City or Town: NrmltUcense #
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, - 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 backfill),
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 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
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