46-058 (2) 503 MOUNT TOM RD BP- 2011 -0704
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc 46 - 058 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: replacement windows /siding BUILDING PERMIT
Permit # BP- 2011 -0704
Proiect # JS- 2011- 001156
Est. Cost: $23000.00
Fee: $70.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TOM KELLIHER IMPROVEMENT 88261
Lot Size(sg. ft.): 117612.00 Owner: GLAZEWSKI HELEN S & MARY
Zoning: SC(100) Applicant: TOM KELLIHER IMPROVEMENT
AT. 503 MOUNT TOM RD
Applicant Address: Phone: Insurance:
25 BEAUDRY AVE (413) 575 -8428
CHICOPEEMA01020 ISSUED ON :31212011 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL SIDING & 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 3/2/20110:00:00 $70.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
City of Northampton
G�
�G
Building Department
212 Main Street
2 Room 100 x
Northampton, MA 01060
13- 587 -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 Prooertv Address
This section to be completed by office
5 -63 Ma p Lot Unit
AJ G Zone Overlay District
Ole
Efrri St CIS District "
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
HA P_ (/ ��.� z c �(> 5 3 /YT IL-7 led
Name (Print) Current Mailing Address:
Telephone _
Signature S f!'
2.2 Authorized Aaent:
Name (Print) Current Mailing Address:
Signat re Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item C � Estimated Cost (Dollars) to be Official Use Only
r S
completed by ermit applicant
1. Building ^L_ (a) Building Permit Fee
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 For Official Use Onl
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspectorof Buildings Date
t
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zo ng
This column to be led in by
Building Departm t
Lot Size
Frontage
Setbacks Front
I
Side L.
R: # L: _ R: £ _
Rear �- - ••-- --
Building Height --°
Bldg. Square Footage % _ _9
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 Q DONT KNOW YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q 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 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:I,
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavatio S r filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all aaplicablel
New House ❑ Addition ❑ Replacement wiWows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [Other [0]
Brief Description of Proposed /
Work:
Alteration of existing bedroom Yes L- - lam Adding new bedroom Yes
Attached Narrative Renovating unfinished basement Yes �o
Plans Attached Roll - Sheet
Ga Cf t .Ct rose aiti� � �addi of / . c f he
a. Use of building: One Family e/ 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? 4
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 Z •, ���� , / /w✓ 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 t he pains and penalties of perjury.
Y
' t "
Print Nam
Sig ature of Owner /Agent Dat
r
SECTION 8 - CONSTRUCTION'' SERVICES
8.1 Licensed Construction Supervisor / Not Applicable ❑
Name of License Holder /P / A LZ M-el_ g� �
License Number
Address 6cpirat' n Date
Signature Telephone
PP
Not Ap ❑
Company Name Registration Number
Address Expirbtion Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25G(.0
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 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 buildine 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
T
The Commonwealth of Massachusetts
Department of Industrial Accidents -
Office of Investigations
600 Washington Street
Boston, M A 02111
1 M 1� `1 i I -
-Workers' Compensation Insurance Affidavit:.Builders/ Contractors %Electricians/PIumbers
Applicant Information Please Print L 4 'blv
Name ( Business /Orgmizatiomindividual):. , Z
-
Address
City /State/Zip: L?- dy U Phone. #:
Are you an employer ?.Check the appropriate ox: of project ( required):. f
1.[1 I am a employer with 4.. [] I am a general contractor and I 5. ❑New construction
ogees (full and/or part - time).* have used the sub- contractors
2.. lam a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship 'arid have no ez-4>loyees These sub - contractors have .8. F Demolition
working for mein any capacity en�loyees_and have workers'
9 Bust a�dion
[No workers' 'comp: iassancer - c0MP. msu ranee Q!
reguired:] 5. We are a corporation and its 10.0 Electrical repairs or additions
3. I am a homeowner doing all work officers havexercised their 11.0 Plumbing repairs or additions
myself= [No workers' comp. rim of exemption per MGL 12. [] Roof repairs
insurance required:] t c: 152, § 1(4), and we have no
emP 1 o workers' 13.0 Oilier
employees. �.
wrap. insuranc required.].
`Any applicant that checks box #1 unist also fin out the section below showing thCirworkers' compensation policy information:
t Homeowners who submit this affidavit.indicating they are doing an work and then hire outside contraciora must submit a new affidavit indicating such.
tConuactors that check tins box must.aaached an additional sheet showing the name of the sub = contractors and state wheel= or not tlaose-entities have
employees If the sub-contractors have employees, tiny must provide their workers' c=V policy number .
l am an employer that isproviding workers' compensation insurance for my employees Below is the policy and job site
information.
Instzance Company Name:
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site Address: City /Stafe/ -
Attach a copy of the workers' compensation policy declaration page'(showing the policy number and eapiratton date).
Failure to- secure coverage. as regni=ed find& Section 25A of MGL c: 15z car Idid to ilie inipos"rtion of cTimmaI penalties of a
fine tip to $1500.00 and/or one -year imprisonment; as well as civil penalties iii the form of a STOP WORK ORDER and a fire
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Invesfisations of the DIA for insurance' covera>e verification: _ :: , � , _.:_ .. .
the in hereby certify u _ the pains and enahies of perimy a& the rovtded- above
f �' _..
sign tore: ate:
Phone
Official use only. Do not write hi this area, to be completed by city or town official
City or Town: PermitUcense #
Issuing Authority (circle ane):
J. Board of Health 2. Building Department 3. CityiTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
, a
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
permits 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