43-049 i
BP- 2010 -0155
GIs #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: S i1'din DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate BUILDING PERMIT
Permit # BP -20 -0155
Project # JS- 2010- 000191
Est. Cost: $1200.00
Fee: $35.00 / PERMISSION IS HEREBY GRANTED TO:
Const. Class: ontractor: License:
Use Group: ?C & T CONSTRUCTION 062884
Lot Size(sq. ft.): 24088.68 Owner: ROBINSON LEE J & SUSAN
Zoning: SR(,100, )//WSP II Applicant: C & T CONSTRUCTION
AT: 40 FAIRWAY DR
Applicant Address: Phone: Insurance:
15 Fairway Drive (413 ) 586 -4965
FLORENCEMA01062 ISSUED ON :811012009 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 8/10/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
City of Northampton .:
Status ofPertni
Building Department Cuj
212 Main Street S a latnt�ty E� w
Room 100 r ater/WelfA•varf bI I N I
Northampton, MA 01060 vr� 5ets of tnicfrtcal PCar . ZV
phone 413 - 587 -1240 Fax 413 - 587- 1272 IoEf£i PIs r
x s R
APPLICATION TO CONSTRUCT, ALTER, REPAI4,f2EtdM OR DEMOLISA ONE OR TWO FAMILY DWELLING
2009
SECTION 1 - SITE INFORMATION AUG `
1.1 Property Address th,� s sec 'on to be completed byoffice
tr.a wu
�= >M J' Lot Unit
one Overtay, Distnict -.
EIm SLDi'strict GB District
SECTION 2 - PROPERTY OWNERSHIPJAUTHORIZED AGENT
2.1 Owner of Record
by o kn-'zo Or- 1 /z///1-V-
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name (Pri / Current Mailing Address:
Signat a 6 Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building 7 l� � (a)- Building Permit Fee
[" a
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) Check Number
This Section Fo Offic 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
Frontage -- - -- --
Setbacks Front
Side L R L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg & paved
p arking )
i# o f Parking Sp aces
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
- - -Ain DONT vein,er n „« -- IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book Page, and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO W DONT KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q 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 Q 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.
s '
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all app licable)
New House ❑ Addition ❑ Replacement ws Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks Siding [Oj Other [01
Brief Description of Propos d /
Work:
Alteration of existing bedroom Yes No Adding new Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa_ If New House and or acldltibn }� �
ta= existing - hoiis�ncr `;oompletetlte:.fa[for�v
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 o. s construction wit 100 yr. floodptain 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 -70 BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, �/�(, i✓l ��� as Owner of the subject
property
hereby authorize
o act ono behalf in all ma ers rel ' e to work auth ri ed by this building permit application.
Si ature of Ownell Date
�� /�p�jC'� y► as Owner /Authorized
Agent here clare that the stat a d 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.
&e,
Print Na
Sign ure caner /Agent Date
r
SECTION -8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supe r visor : Not Applicable ❑
~
Name of License Holder
License Number
Address l Expiration Date T-
-
Signa a Telephone
9.:Re isteted' Kor a l "mpto`ve iYent..Gontractor- -' m rf Not Applicable ❑
_Company Name Registration Number
61C "2
Address V /� Expiration Datb
Telephone O��A
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...... ❑
11.. o ell el>E ptTaiJ€
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 -vear 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
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
i
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: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Le ibly
Name ( Business /Organization/Individual):
Address —fj /i X,-cry � 0r
City /State /Zip: lave 2e-e. 0IO2Z Phone. #:
Are you an employer? Check the appropriate bog: Type of project (required):
1.0 I am a employer with 4. � I am a general contractor and I
6. r_1 New construction
�e �loyees (full and/or part- time).* have hired the sub - contractors
2. EJ 1 am a sole proprietor or partner- listed on the attached sheet. 7. KMemodeling
ship and have no employees These sub - contractors have g. (] Demolition
working a employees and have workers
g for me in any capacity. tY 9. F] Building addition
lino workers' comp. insurance co w ' " """''` t
required.] 5. F1 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 1 I.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any applican a c ec ox must a o t out a section a ow showing eir wor ers' compensation policy info —tion.
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.
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 # or Self -ins. Lic. #: Expiration Date:
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 $1,500.00 and/or one -year 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. Be advised that a copy of this statement may be forwarded to the Office of
InvestiEzations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties f erjury that the information provided above is true and correct
Si afore: �/ Date:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #: