16D-017 (2) 177 NORTH MAIN ST BP- 2011 -0503
GIs #: COMMONWEALTH OF MASSACHUSETTS
Ma :Bloc 16D - 017 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate o ry : BUILDING PERMIT
g
Permit # BP- 2011 -0503
Proiect # JS- 2011- 000825
Est. Cost: $1850.00
Fee: $150.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARTIN CUSTOM MASONRY 77732
Lot Size(sq_ft.): 18295.20 Owner: KOESTER JAMES F & JEAN M
Zoni URB(100 / Applicant: MARTIN CUSTOM MASONRY
A3c 17T N'GRTH {>AWN ST
Applicant Address: Phone- Insurance:
103 SHERIDAN ST (413) 592 -3595
CHICOPEEMA01020 ISSUED ON. 12/1/2010 0:00 :00
TO PERFORM THE FOLLOWING WORK.- REBUILD CHIMNEY
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: Q
THIS PERMIT MAY BE REVOKED BY THE CITY OF THAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND RE
d o e " lzvo
Certificate of Occu anc nature:
FeeType: Date Paid: Amount:
Building 124/2010 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
BP- 2010 -1114
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)
Category: BUILDING PERMIT
Permit # BP- 2010 -1114
Project # JS- 2010- 001634
Est. Cost: $500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 24262.92 Owner: SENSER JOHN E
Zoning. URB(IOO)/ Applicant. SENSER JOHN E
AT. 147 NORTH MAIN ST
Applicant Address: Phone: Insurance:
(413) 584 -5995 (1
FLORENCEMA01062 ISSUED ON. 61912010 0:00:00
TO PERFORM THE FOLLOWING WORK.- REPLACE SHINGLE W /METAL ROOF
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 6/9/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
City of Northampton
Building Department
212 Main Street
- Room 100
Northampton, MA 01060
phone 413 -587 -1240 Fax 413 -587 -1272
APPLICATION TQ_CONSTR_U6T, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 11 -SITE INFORMATION
1.1 Prooertv Address This section to be completed by office
I7 m S ) Map ~ Lot lJni
Zone ` 1verlay Distrrct Y
f Lu'o, Q,n c_e� mi �\ Q 1 p
€hri $t Diattict CB Distrtc[ `
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of \ \ Reco rd:
Name Curren Ii g Address:
r -bh co-
Telephone
2.2 Authorized Agent: O
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 0 � �j (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building iPermit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Secdon For Official Use Onl
Date
Building Permit Number. Issued
Signature:
Building Commissionerlinspector of Buildings Date
Section 4 ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Ibis column to be filled in by
Building Department
Lot Size !
Frontage I
Setbacks Fron - —
Side L: __ R L= R: i
Rear _!- --
Building Height — -- 1
Bldg. Square Footage��
Open Space Footage
(Lot area minus bldg & paved park
# of Parking Spaces 1-- -.-
Fill: I I
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW ® YES
IF YES: enter Book 6 Page! and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 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 0 NO 0
3
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO
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 ® 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 Alterations) ❑ Roofing
Or Doors E3
Accessory Bldg. ® Demolition ❑ New Signs [O] Decks [[M Siding [O] Other [�]
Wo
r i c D escription of Proposed o ��I Q I �.-� -A�
Alteration of existing bedroom Yes Y No Adding new bedroom Yes k No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
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 Co Compliance. Masscheck Energy Compliance form attac
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'
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 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 pedury.
Print c
ignature of Owner /Agent Date
SECTION 8-- CONSTRUCTION. SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
..,'.�.A PP
Not Applicable ❑
A ��
Rets6erlimiroytteb itr�c#or _ . Y �
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § I25C( &)) ',
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 i aw a e es....... U 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.
Th undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
orthampton 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, MA 02111
• www.mass gov /dia
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers
Applicant Information Please Print Legibly
Name ( Business /organization/Individual): .
Address:
City /State/Zip: Phone. #:
Are you an employer?. Check the appropriate'box.- Type of project (requir]d' 1. ❑ I am a employer with 4.- E] I am a general contractor and I
employees (fall and/or part time). * have htred the sub- contractors 6. ❑ New coistruction
2_ El I am a sole proprietor or partner- listed on the attached. sheet 7. ❑ Remodeling
ship -and have no loyees These sub- contactors.have. .8. [� Demolition
working for -me in any capacity. cm�Ioyees;and Izaye worTtiers' : _ -- Q - • - ddiddn -_ a No work= r comp. hisur-ance requir5. � We arc a corporation and its 10.0 Electrical repairs oX right xercisect their 11.0 Plumbing repairs o
f myself [No workers' comp. Of exentptiori per MGL I2.� Roof repairs
insurance req uired:] t c: 152, § 1(4); and we have no
o - --
comp. insivance required.].
'Any appiic an 4hat checta box ill must also fin out the section beloashowing theirworim co tian policy i.formation.
t Homeowner; who submit this affidavit.indicatiag they are doing all work and then hire outside contractors must submit t a new affidavit indicating such.
IConuactors that check this box must attached an additional sbeet showing the name of the sub contractors and state whether-ornot-those entities have
employees. If the sub -cunt actors have employees; they must provide their wo icers' contp..pofiey number.
I am an employer that 1s providing 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: C State/
rty / ziP=
Attach a copy of the workers'' compensation policy declaration -"g the policy number and expiration date).
Farlure . to secure coverage. as requirml undcr.Section 25A'ofMGL&. 152 can "' lead_to flee imposition Ofcrimm�I -
.. penalt<es of a
fine up to $1,500.00 and/or one.- year as well as civil penalties in the form of a STOP WORg�QRDER and-a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Oji'ce of
]`rivest�tTations'of thc'bIA for coverage
I do ehy certify rrs penalties ofPerjruy that "the ca ormation rovi
under the pai ded aliovE ssiue_aadrarr- ect_:�
f
ten e: q aft
Phony
FOthe only. Do not write in this area, M he comp by a5 Tor Town officcaL
Town: Permit/Llcense #
ority (circle one):
ealth 2. Building Department 3. City/'Town Clerk .4. Electrical Inspector 5. Plumbing Inspector
son: 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
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
- -- -
youccaled), i nsulation -
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, S — understand the above .
owe owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued tome.
Date )OVA I
Address of work
location