16D-023 BP- 2010 -0430
61S �1: COMMONWEALTH OF MASSACHUSETTS
f CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
CateL BUILDING PERMIT
Permit # BP- 2010 -0430
Protect # JS- 2010 - 000585
Est. Cost: $1800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
C onst. Class: Contractor: License:
Use Group: NATHANIEL DAVIS 084975
Lot Size(sg. fu: 32887.80 Owner: WITMER JAMES R II
zonim -- T'R_a_ (41)!i?RB(59 /W Applicant: NATHANIEL DAVIS
AT. 140 NORTH MAIN ST
Applicant Address: Phone: Insurance:
18 PLEASANT GREEN (WEST) (413) 529 -0608
EASTHAMPTONMA01027 ISSUED ON. 1012312009 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR FRONT PORCH
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 10/23/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -0430
APPLICANT /CONTACT PERSON NATHANIEL DAVIS
ADDRESS /PHONE 18 PLEASANT GREEN (WEST) EASTHAMPTON (413) 529 -0608
PROPERTY LOCATION 140 NORTH MAIN ST
MAP 16D PARCEL 023 001 ZONE URA(41)/URB(59) / /WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid Ap
Typeof Construction: REPAIR FRONT PORCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 084975
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOv1rATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
_ _Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demol'tion Delay
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
3
City of Northamptontatt,��
Building Department
212 Main Street 5lblt>
Room 100
Northampton, MA 01060 e
�__ -_ 4An 5n9 An An ["•.... AA7 C 7 4
P hone `t 1 J-JO / - 1 L4V Fax °F 1 J / - � G / G ��u a r
, , y aim 10
APPLICATION TO CONSTRUCT. ALTER. REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION,
1.1 Provertv ddress: This section to be completed' by office
/[ O �Ofs 11 r 1 Map Lot Unit
1
Zone Overlay District
Efm:St. District C13 District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 wner of Record:
``I,,r, - -- - - - -- - - - - - -- - -
Name (Print Current Mailing Address:
!�. Telephone
Signature
uthorized Aqent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applica nt
1. Building ` (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
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
This column to be filled in by
Building Department
L ,.,,..._......,.._.__.....,...
Frontage
Setbacks Front
Side L. ..._... R. '.. _..,_.._ L: ._.., _.. _ _ R
Rear
Building Height
Bldg. Square Footage v '_ /o
Open Space Footage % _. ...
(Lot area minus bldg &paved
p arkin g)
# of Parking Spaces -- -
- -- 7 z _
Fill:
(volume &Location � ...w.....
A. Ha a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KN 0 YES
IF YES: enter Book = Page and /or Document #'
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 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 ofsigns intended for the property ? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, gradi excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
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 Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [O] Other [�
Brief tion of Pro ed
work. p - a f i n,. o s S Z �I ' 1 r
Alteration of existing bedroom Yes_ No Adding new bedroom Yes No .� a
Attached Narrative ! Renovating unfinished basement es No
Plans Attached Roll - Sheet
ga 'lf�E
_eru,'h ,use_a;��" ar, .acCdi�l��rt� e�is�ift �i'c�>flsi� Coen Tef a fi(e faCfouirirt
a. Use of building : One mily Two Family Other
b. Number of rooms in each fa it: Number of Bathrooms
c. Is there a garage attached.
d. Proposed Square footage of new constru Di ions
e. Number of stories?
f. Method of heating? fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mas eck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of lands? Yes No. Is construction hin 100 yr. floodplain Yes No
j. Depth of basement or ar floor below finished grade
k. Will uildin nform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - NER AUTHORIZATION - TO BE COMPUTED WHEN
OWNERS A T OR CONTRACTOR APPLIES FOR BUILDING PERMIT
7 A,0J J_ �,• I rvCr �_ as Owner of the subject
property
hereby authorize a J j
to act on my behalf, in all matters relative to work authorized by this building permit application.
// "/ , o
Si nature of OwKer Date
I, li.'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 w3de the pains and penalties of perjury.
Print a'me -
�., i� C 5 A
ignature of ner /Agent Date
y
a
SECTION 8 - CONSTRUCTION' SERVICES
8A Licensed Construct i n Su erv' or: Not Applicable ❑
Name of License Holder ; V r
1 P3 License Number
e Y 8 0, 1 J - z' 0 1
Address Expirat on d to
��z a 41UZ
i nature ephone
istereilEfu€r I':s ° ," veirfenCor�fr'cf& ., : _ � F.. .. a M., . `. r ..;, Not Applicable ❑
Coml2any Narfte Registration Number
1 4 go) 0
Address Expirati n Date
Telephon
S ECTION 10- WORKE 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...... ❑
KAI
The-current-exemption for meo.__ " was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an ividual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780 Sixth Edition Sect 108.3.5.1.
Definition of Homeowner Person (s) who own a cel of land on which he /she Zreside ntends to reside, on w hich there
is, or is intended to be, a one or two family dwelling, a ached or detached structy to such use and/ or farm
structures. A erson who constructs more than one ho a in a two- ear erio be considered a homeowner.
Such "homeowner" shall submit to the Building Official, o form acceptab o the Building Official that he /she shall be
responsible for all such work Performe d under the buildi vermit.
As acting Construction Supervisor your presence on the job s wi e 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' om ensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Mass usetts neral Laws Annotated, you maybe liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assum responsibility for mpliance with the State Building Code, City of
Nort�amptort r in`ances; State anc oat end State of tts- General- LawsAnnotated.
Homeowner Signature �;
T
i The Commonwealth of Massachusetts
Department of Industrial Accidents -
Office of Investigations
600 Washin Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers
Applicant Information ai it Please Print Legibly
Name ( Business /Organization/Individual): We
Address: Q,
City /State /Zip: I /V Phone .#j m ]2-"' F32 r j
Are you an employer?- Check the appropriate box: - - ]�
Type ofpraject Crequii
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
2- am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have. no. enmplo;yees These sub - contractors have. .g. Demolition
working' for me in any capacity. employees and have workers' 9. Building addition
(No workers' comp. insurance comp..insurance.
required: required: j 5. We are a corporation and its 10.0 Electrical repairs or additions
-am -a- iomeewner- doing- wc�k- - - -- —_ ___� c s a x ezcas cl their -_ 1. 1?lu ing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t C. 152, § 1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insuran required }
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating theyare doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors 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 workers' comp. policy number.
I 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. 132 can lead to the imposition of criminal penalties of a
fine up to $1 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. 1�e advised that a copy of this statement may be forwarded to the Office of
Investieations e for insurance c erification.
I do kereb ' rtify u d th rpm enalties of rjury that the information provided_above is-true- andcorrecz
Signature: - - - a te;
Phone #: F 2 -
Official use only. Do not write in this aced, - to be cotnpfeied by city or town ociaL
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical I nspector 5. Plumbing Ins pector
6. Other
Contact Person: 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
dwe1U attached or detached structures accessory to such use and/or farm structures. A
person wN constructs more than one home in a two -year period shall not be considered a
home owne "
The building de arrient for the City of Northampton wants person(s) wh eek to use
the home owner exemption, to act as their own construction supervisor, , be aware that
by doing so you become responsible for compliance with state bu' ing codes and
rrwpem _ - regulations The insr�+ection n requires that the building dep inent be calle to
inspect work at various' tages, which include foundation /footin ' efore backfdl
sonotube holes before ur . a rou h buildinLy inspection efore work is
concealed insulation ins ection if re uired and a Tina uildin ins ection. The
building department requires' inspections before the ork is concealed, failure to
secure- these, ins ections.can - sult in failure to obtaiA a certificate of occupanc
until the work can be ins ecte
If the homeowner hires other trad to perform war (electrical, plumbing & gas) the
homeowner will be responsible to make sure that a trades hired secure their proper
- -- - , - - - - -- permits --i_n- can }unction- .to_th ` ermit.' ed,_and_that they get their required
al t d
inspections. Failure of the individues t secure, the permits and inspections as Y
required can DELAY the project until su ime as the proper permits and inspections are ,,. J
made
I, understand the above.
.(Home owner /resident's si ature requesti exemption)
I will call to schedule all requi d building inspecti ns necessary for the building permit
issued to me.
Address of work
location