43-062 32 )t HY]7R' BP- 2010 -0452
GIS #: COMMONWEALTH OF MASSACHUSETTS
MA&A A
t: = � CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Gate orv: BUILDING PERMIT
Permit # BP- 2010 -0452
Project # JS- 2010- 000618
Est. Cost: $6500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq_ft.): 15333.12 Owner: RICHARDSON KATHLEEN & BRIAN
Zoning: SR( 100) //WSP II Applicant: RICHARDSON KATHLEEN & BRIAN
AT. 32 DUNPHY DR
Applicant Address: Phone: Insurance:
32 DUNPHY DR (413) 584-27410
FLORENCEMA01062 ISSUED ON :1012312009 0:00:00
TO PERFORM THE FOLLOWING WORK REPLACE SHAKE WNINYL SIDING
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Li nderground: 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 10/23/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
City of Northamptontatc�sfrilt
B ilding Department Cx#'tfseway P�ltj u
C� --
12 Main et
Room 00
hampton, MA 01060 Tuoet €�r�tr'
v ✓ J prr€413- 587 -1240 Fax 413 -587 -1272
A�'PLICATION 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
�u kA Ph �-')I
Map Lot Unit
1 Zone Overlay District
EimSt District CB District
SECTION s2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Own erof Record:
",
Na (Print) Cu ailin dress:
I -
l%L i` '�1G f�., 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 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost u
Construction_ from 6'
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Sectinn Fnr )ffirial UsP oliiy
Building' Permit Number. Data
Issued:
Signature:
Building Commissioner /Inspector of Date
a
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
LotSize _ . __,: _.__.. _.„ ._,____.,_ M ,_ _..,. _ _ . _..,.
Frontage _. ._ __. ..__,._ __ _. _.,,_._.. -. ,
Setbacks Front
Side L: .,m...,_w. R. L__.,_.... L
Rear
Building Height
Bldg. Square Footage
Open Space Footage _ % _ ._.,,_,.
(Lot area minus bldg & paved '
# of Parking Spaces
Fill:
(volume & Location) '
A. Has a Special Permit/ Var a nce/ Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:;
IF YES: Was the permit reco at the Registry of Deeds?
NO DOIJT KNOW 0 YES d
IF YES: enter Book Page' and /or Document #,
B. Does the site contain a brook, body of water or wetlands? NO 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 klik
IF YES, describe size, type and location:
m� _�t�
f�iere`any propos��an4es to or ac� dlfions of signs ihfended for the property ? YES � NO
IF YES, describe size, type and location:
E. Will the construction activity distt rb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
eN
that will disturb over 1 acre? Y =S NO
IF YES, then a Northampton Stoi m Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding [I;Iel� Other [O]
rief DescriF�tio of P p sed
Work: v I l� �i / r` rot 1 c� ti'_ l� llr (
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa_ ff_N6, hous6 %a d Or adiit #ior lLo a isfilrig housing,..comiptete >the foCla�n►�rrg:
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
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, as Owner /Authorized
Agent h reby declare that the statehie 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 7�t//_.4—
Signatu of Owner /Agent Date
6
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9, Registered Hom"nibrovemenybbritractor " , , Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTIO 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...... ❑
.� �
- _The_cuuent_exempiion for.`_`homeov✓ners" was ext ended 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 108.3.5.10
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 pe rmit.
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.
Aloo be ads iecd that with rPfPrPnretn ('haptrr 157 (Wnrknra' 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)
u ohire - to - er�orm w ou
r,
ork - for - tmderthi i
The undersi "homeowner"
y gn certifies and assumes responsibility for compliance with the State Building Code, City of
Gerrer -al- Laws - Annotated.
_
o ampton Ordinances, ST e o
J Homeowner Signatur
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov /dia
- Workers' Compensation Insurance Affidavit: Builders / Contract :ors /Electricians/Plumb.ers
Applicant Information Please Print Lesibly
Name ( Business /Organiiation/Individual):
Address:
City /State /Zip: Phone. #:
Are you an employer? Check the appropriate box:
Type of project (required):.
1.0 I am a employer with 4.. E] I am a general contractor and I
employees (full and/or part-time).* have hired the sub- contractors 6. ❑ New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet 7. EJ Remodeling
These sub - contractors have.
ship and have. no. a le, =ees , . 8. EJ Derno,
ition
working for me in any capacity. employees and have workers'
9. Buzz addition
[No workers' comp. insn comp..ins
required.] 5. We are a corporation and its 10-El Electrical repairs or additions
I am a h
3. me _-_— ._ cer v� eSSis� t}zei�_ 11: min
-- 1 gl g- r r
epairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insuran required] t c. 152, §1(4), and we have no 13.� Other
employees. [No workers'
comp, insuran 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 aidavit indicatingthey 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
formation.
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).
a
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimingl penalties of a
fine zip 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. lye advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereb ' ee nder th
- _y fy pains and pen ofper�ury that the information provided above &- true -andcorrect___
/S ature:
ate; I
Phone ##: `f ? J` c7 (F l
Offcial 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):
L -Board of Health 2. Building Department .i. City/Town Clerk 4. Electrical I nspector 5. Plumbing Ins ector
6. Other - - - - r
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
- The in�ne_ction Droc requires that the building department be calle 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
--- -- e- =ts- in- conjunction..to the_bu ng-p eunitissued,- 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.
( ome owner /resident signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
e
Address of work
location