44-006 908 FLORENCE RD ; BP- 2012 -0139
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map-Bloc 44 - 006 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofin BUILDING PERMIT
Permit # BP- 2012 -0139
Project # JS- 2012 - 000204
Est. Cost: $6000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 20908.80 Owner: MILLIGA' K COLLEEN P HEINTZ
Zoning: SR(100)//WSP 11 Applicant: MILLIGAN JOHN K COLLEEN P HEINTZ
AT. 908 FLORENCE RD
Applicant Address: Phone: Insurance:
908 FLORENCE RD (413) 320 -5693 (�
FLORENCEMA01062 ISSUED ON:81412011 0:00:00
TO PERFORM THE FOLLOWING WORii: STRIP,PLY & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM '! , 'STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Pieter:
Footings:
Rough: Rough: I!. # Foundation:
P a Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE C 'Y OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amwl
Building 8/4/20110:00:00 $35.0(?
212 Main Street, Phone ( I ' ) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouc!: - Building Commissioner
ty of Northampton
B 'Iding Department'
12 Main Street
• A ���� Room 100
rth mpton, MA 01060
1240 Fax 413 - 587 -1272
F."o-
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
'SECTION 1 -SITE INFORMATION
1.1 Property Address
This:sectionto be completed by:office
C> 13 �L re#n C'e /Cj Map Lot lJni
F r Zone Overlay restrict %
m
..:
EIS Si b!stdct CB District
SECTION 2 -PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
- M%n Milli-Ol B o g r o r z,
Nam (Print) Current Mailing Address: 2� 16 13
Telephone
Signagire
2.2 Authorized Anent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building O O (a) Building Penmt Fee
2. Electrical (b) Estimated Total Cost of
. Construction from 6
3. Plumbing BuildingPermitf
4. Mechanical (HVAC)
5. Fire Protection
6. Total= 0 + 2+3+4 + 5) 6 0 0 Check Number
This Section F.or Official Use Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissionertinspector of Buildings Date
Section 4 . ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incom lete fnformatio"i
Existing Proposed Required- Zoning
This col to be filled >in,$
Building arttnent
Lot Size �ca a
Frontage ( r
Setbacks Front
Side L: R: L: R: 3
Rear
Building Height��
Bldg. Square Footage % - -
—Open Space Footage _ % - - -- - - - - -- — _
(Lot area minus bldg & paved
p arkin g)
# of Parking Spaces
Fill:
volume & Location I
A. Has a Special Permit /Variance /Finding ever been issued for / on the site?
NO � DONT KNOW 0 YES 0
IF YES, date issued:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book Pag and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES Q
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
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:
i
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.
SECTION 5- DESCRIPTION OF!PROPOSED WORK (check all aaalicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 1Z
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks (Q Sidi [ ] Other [oj
C
Brief Descnp 'on of P oposed STr fn - old
�° c
Work: O CR - r y I o o r - e-v 2C t� f�0 � - Lt✓ a l� �i-ep� tv'
Alteration of existing bedroom Yes /` No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes _ No ` Q �` T
Plans Attached Roll - Sheet ' 4 p,4
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: 1 Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. a!/1q _ Dimensions
e. Number of stories? r
f. Method of heating? b 1 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 _X No. Is construction within 100 yr. floodplain Yes No
C 1
j. Depth of basement or cellar floor below finished grade d
k. W111:1building conform to the Building and Zoning regulations? X Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a -OWNER AUTHORIZATION TO BE COMILE7ED WHEN ;
OWNERS AGENT OR CONTRACTOR APPLIES F B[IILDING PERMIT
I, as Owner of the subject
propert
hereby authorize (� (� I I � P. I h 7 r� r' - �� n ^ \�D �t v� (>( • 11 l �1 Gyy�
to a on behalf, in all rs relative to work au ohs razed by this building permit application.
Zvi
Signatir of Owner Date %
I, -- To Vt n V V t of G�► yl as Owner /Authorized
Agent hereby declare that the sta ements 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
Pnnt Name
2a i
Signature of Owner/Age2o Date
.o
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor pp i ' Y
Not A licablt;
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
;l btee Not Applicable fl
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- 1NURKERS`; COMPENSATIQN INSURANCEliAFFIDAVIT (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 _ofthe 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 Zoninta of MassachusettsGeneral Laws Annotated.
Homeowner Signature
The Commonwealth of Massachusetts .
Department of Industrial Accidents. .
Office of Investigations
600 Washington Street
Boston, MA 02111
y,.massgov /dia
- Workers' Compensation Insurance Affidavit: 1 uilders/ Contractors /Electricians/Plumb.ers
Ap plicant Informations h h'I r (ig �� Please Print LeeibIy
Name ( Business /Orgmization/Individual): -QC-
Address:
O ,� F Lare4 c-e a
City /State/Zip: Phone. #: [ �i 7 6 �l 3
Are you an employer?. Check the appropriate'boz:. -Type of project (required):.
4.. [] lam a general contractor and I
1. ❑ I am a employer with 6._❑ N co nstruction_,_
_ * -- have hued- the- sub••contractors - --
"— employees (full and/or part time:
2.. El I am a sole proprietor or partner=
listed on the attached sheet. y (] Remodel
- ' ship' and fiave. no eloyees
- -- These sub= contractors -have. - .8. [D Demolition
' ❑ Buil
working for me in any capacity. employees and have worke rs 9: ding addition
comp, r suran
[No workers comp: insuranc 10. Electrical airs or additions
required ] 5• E] We are a corpo •ration and its ❑
3. I am a homeowner doing all work officers have.exercised their 11.❑ Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, § 1(4) and we have no 13.E] Other
employees. [No workers'
comp. insurance required }. -
"Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information.
t Homeowners who subs it this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
IContmctors that check this box must .attached an additional sheet showing the name of the sub= contractors and state whct'heror not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
f 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
Investieations of the DIA for insuran coverage verification.
I h un ereby ce the airs �-an e o f perjury that the information provided above is true and correct
i ture:- Date: U. 20i(.
Phone #• y 3 3, ` �- 6R3
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):
I. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other ' ~
Contact Person: Phone 9: I
T
.0
f
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 persons) who.. to use
the home owner exemption, to- act as their ewrr construeton 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 n final building inspection. The
building departm r equires_ these_inspe before the work is concealed, failure. to
secure these insQections 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
T, �; , understand the above.
.(Home owner /resident's signs re requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me:
Date
Address of work
location