44-044 254 EASTHAMPTON RD BP- 2011 -0193
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map 44 - 044 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- 2011 -0193
Project # JS- 2011- 000337
Est. Cost: $1000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME OWNER EXEMPTION
Lot Size(sq. ft.): 61855.20 Owner: Richard Huntley
Zoning: GI(100) Applicant. Richard Huntley
AT. 254 EASTHAMPTON RD
Applicant Address: Phone: Insurance:
PO Box 172 (413) 207 -1782 0
NORTHAMPTONMA01053 ISSUED ON.
TO PERFORM THE FOLLOWING WORK.- Replace porch piers
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 9/3/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
City of Northampton
Building Department `
212 Main Street
Room 100
Northampton, MA 01060
4hcme2413487 -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 sectiomto be completed by office
r a �� r I Unit
Map dot
/- � /�"'� Zo�ie `Overlay_pistrict
Efrn:St Diatrlct CB.District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
alc -l- UN7' �0%6 X /7a
Name (Print) Current Mailing Address:
'207 f 78.E
'-� Telephone
Signature
2.2 Authorized Aaent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only "
com feted by ermit applicant
1. Building (a) Building Permit Fee C C'
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) O C, Check Number
This Section For Official Use Onl
� E � ` �
Building Permit Number: 41 3 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 ) i
Frontage
Setbacks Front
Side L: R: L R:
Rear
Building Height 1 t
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg & paved�_ _
par
# of Parking Spaces --
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNO 0 YES 0
IF YES, date issued: j
f
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW f YES 0
IF YES: enter Book i Page and /or Document #'
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued
C. Do any signs exist on the property? YES 0 NO Q
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 0
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
1
SECTIONS- DESCRIPTION OF PROPOSED WORK (check all aaalicablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [0] Other [0]
Brief Description of Proposed
Work: PRS LU N - Q5 5 Z Po /-1
Alteration of existing bedroom Yes _j9<, No Adding new bedroom Yes _� No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
Sa .If -: SIII lOt1 Q l� O ''.0",A r C It1�Ct " cis i>f tE i ' Ql TtlfiSMtt t ':
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 COMPMT.El7' WHEN'
OWNERS AGENT OR CONTRACTOR APP LIES 'FOR BUILDING PERMIT
I, L as Owner of the subject
property
hereby authorize
to act on my be If in all atte relative o ork authorized by this building permit application.
Signature of Owner Date
I, 12 ! e_j4%?7> dbIJ7 - L!�X as Owner /Authorized
Agent hereby declare that the statements 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.
Print Name
; Z� �4�_ 3 /U
Signa ure of Owner /Age t Date
1 ,,
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Rei lmgelrii�iitlllar ��«�.. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25G(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...... ❑
rn ct
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 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 L cal Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
. T
The Commonwealth of Massachusetts
Department of Industrial Accidents .
Office of Investigations
_ 600 Washington Street
Boston, MA 02111
www.massg oVlifla
-Workers' Compensation Insurance Affidavit: Builders/ Cont ractors/Electricians/PIumb.ers
Applicant Information Please Print Legibly
Name (Business/orgm izadomIndividual): L IC-Li /c' �yI CSC
Address: ); / ,
City /StatelZip: L S �, ! 7! CSIOS Phone. #: 7 a
Are you an employer? Check the appropriate box: Type "project (required):. /
1. El am a employer with 4.. E3 I am a general contractor and I
employees (full and/or part-time).*
have hired the sub- contractors 6. ❑New construction
2. EJ I ani a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no: e�loyees These sub - contractors .have. .8. ❑ Demolition
working for me m any capacity employees_ -and have workers' 9: Biiild� addition
[No workers' COTIIp inS'linaneC - comp ineixanr•P f._ ""`b .
5. We area co 10. Electrical r
equir oration and its
ed ] corp repairs or additions
3. a homeowner do' all work officers havexercised their I1. Plumbin r
❑ g epairs or additions
myself No workers' comp. right of exenaptiou per MGL 12:[r3TRoof repairs
insurance required-] t P. 152, § 1(4), and we have no 13 Other
employees: [No work='
comp. insurance required.] .
*Any app &cant That theca box #.1 m=also fill out the section below showing theirworkers'tonPeasation policy information:
t Homeowners who submit this affidavit.indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such:
ICoatractors 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 worlds' comp. _policy number.
lam an employer that isproviding workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self-ins. Lic. A Expiration Date: -
Job Site Address: City /Stafe/Zip:
Attach a copy of the workers' compensation policy declarafion page'(showing the 9h cy num u
ber and on date .
P.
Failure . to secure coverage:as requi �ed un Section 25A'of1VICrL c 15z can lead to 8�e ' -' sihon of criminal penalties of a
fine up to $1,500.00 and/or one- year as well as civil penalties in the form oo STOP WORK ORDER and-a fine
of up to $250.00 a day against the violator. Be advised that a co .
_ PY of this statement may forwarded to the Offi . ce of _
Investigations of the 'W for m§uraud a coverage ; veriticaiion
I do hereby certi un the arns-and p ofpe{Irny:ticat the informationpro and-correct.
Si lure: 3 l a
Phone #: - —
Official use only. Do not write in this area, to he completed by a5; or town offu w
City or Town: PermitUcense #
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 #•
i R
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 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 to
Date
Address of work
location
crc I
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