16C-031 (5) Y * = BP-2010-0579
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate BUILDING PERMIT
Permit # BP- 2010 -0579
Project # JS- 2010 - 000826
Est. Cost: $4700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 31319.64 Owner: COTE - HOUGHTON DOROTHY & DAR
Zoning: Applicant: COTE - HOUGHTON DOROTHY .& DAR
AT. 383 SPRING ST
Applicant Address: Phone: Insurance:
383 SPRING ST (413) 586 -5422 O
FLORENCEMA01062 ISSUED ON. 121312009 0 :00 :00
TO PERFORM THE FOLLOWING WORK.-INSTALL WOODSTOVE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
t'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 12/3/2009 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
4
City of Northampton Sfa s ert t� z t
30ding Department
- 212 Main Street a`1 �
Room 100�j
ohaM Unon — zs
phone 413 -587 -1240 Fax 413 - 587 -1272 --
P.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address
r Map Lot Unit
Zone Overlay District
Orn St District CB District
SECTION! 2 - PROPERTY OWNERSHIP[AUTHORIZED AGENT
2.1 Owner of Record:
AA,?A? WL A
Name (Pd Current Mailing Address:
�[�L �/ oa /� - i6S y2Z
y Telephone T
nature
1,
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 . ESTIMATED! CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Ilse Only
com leted b ermit a licant
Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Constructionfrom 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section ForOffelal Use bill
`Permit Number: Date
Buildin
g °Issued:
Signature:
Building Commissioner /Inspector -of Buildings - Date
F
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
tee.
Lot Size
Frontage
Setbacks Front
Side L. ?___._ ' R m.__... - 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 /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW 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 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued: i
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
........ _.. _ .
- "" D ' %ire t ere an ro ose can es to or a rtion� s o Rsi nsintended f tfie l ro "ert ?
YP P g g P P Y YES 0 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.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or UoorS 1:1
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding [p] Other [o]
Brief Description of Proposed
Work: Sirs r4 er_ %rie�,( sTe ✓r
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa 1f,.New house ari`rl, or ac�clrtlon °:ta e�istlng'�tousing,. coc»plete�ti�e #olouiiin:
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, ✓� 2DT/`/�' ,a. �o. i-/z r� 6��iz 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 the pains and penalties of perjury.
Print Name
7
Date
Signature of Ownq /Agent
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
Address Expiration Date
Signature Telephone
9.::Reglste "red. Home= lmprovenenl�tintrctor: 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-current-exemption for `Umeowners "_was ex tende d 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.
T e undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
o ampton r marices, w e an tts- 6ener -al - Laws- Annotated.
Homeowner Signature
d
Y
y The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
s - www.massb av /d,arz
-Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Lejibly
Name ( Business /Organization/Individual):
Address:
City /State /Zip: Phone - #:
Are you an employer? Check the appropriate bog: Type of project (required)
1. ❑ I am a employer with 4.. ❑ I am a general contractor and I 6. ❑New construction
employees (full and/or part-time). * have hired the sub- contractors
listed on th
2. ❑ I am a sole proprietor or partner- e attached sheet 7. ❑Remodeling
ship and have. no emp loyees These sub - contractors have .8. ❑ Demolition
working employees and have workers'
g for me in any capacity. ty- � - 9. ❑Budding addition
[No workers' comp. inrui ce compAnsumnee.
required ] ; 5. ❑ We are a corporation and its 10 .0 Electrical repairs or additions
3. F I am- aehome o- -- - - - - -- -- ___ _ �ersav is�d_thei� — I -f:-❑- Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs
insuran required-] t c. 152, §1(4), and we have no
employees. [No workers' 13. [] Other
comp. insurance required-J.
*Any applicant -that checks box #1 must also fill out the section below showing tbeir workers' corr;=salion policy information.
t Homeowners who submit this affidavit. indicating they are doingall work and then. him outside contractors rnustsubmit anew affidavit indicating such.
IContractors that check this box must attached an additional sheet showing the name of the sub=contractors and state whether or not those entities have
empl If the sub - contractors have employees, they must provide their workers' comp. policy number.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Add 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 eau Iead 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. ge advised that a copy of this statement maybe forwarded to the Omce of
Investi:'ations of the DIA for insurance coverage verification
T do hereby certify under the pains and penalties ofperjury that the information provided_above islrue and- correct -.—
ate: ,
Phone 4: y/ 3
- Official use only. Do >7ot ►vr'rte in mis area; tobe completed by city or town of}icaL
City or Town: Permit/License #�
Issuing Authority (circle one):
I: Board of Health 2. - B_ _uildins Department 3. City/Town Clerk 4. Electrical_ Inspector 5. Plumbing Inspect
6. Other =
Contact Person: Phone #:
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
"4ulation ction n c�ss�e fires that the building department be call 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 a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure_#hese:insgections 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.- conj.unction_.to- the- buildin n .rm 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.
- m ime ' owier /resident's signairure requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Address of work
location
i