17A-039 (2) 1� ;gym BP- 2011 -0366
GIs #: 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 c.142A)
Category: B UILDING PERMIT
Permit # BP- 2011 -0366
Project# JS- 2011 - 000609
Est. Cost: $5750.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANDY 077431
Lot Size(sq. ft.): 11717 Owner. LAWRENCE - RIDDELL MICHAEL K & LAUREN C LAWRENCE - RIDDELL
Zoning. URA( 100) //RI Applicant: MARK LANDY
AT. 200 BRIDGE RD
Applicant Address: Phone: Insurance:
P O BOX 61 (413) 625 -6999 (�
ASHFIELDMA01330 -0061 ISSUED ON. 1012512010 0:00:00
TO PERFORM THE FOLLOWING WORK .- SPLIT BEDROOM TO 2 - MUST UPDATE
SMOKE & CO DET & EGREE WINDOW
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 10/25/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP- 2011 -0366
APPLICANT /CONTACT PERSON MARK LANDY
ADDRESS/PHONE P O BOX 61 ASHFIELD (413) 625 -6999 Q
PROPERTY LOCATION 200 BRIDGE RD
MAP 17A PARCEL 039 001 ZONE URA(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid JrOLI
Typeof Construction: SPLIT BEDROOM TO 2 - V + �
New Construction s jvv , :�.
Non Structural interior renovations
Addition to Existing V e—
Accesso1y Structure
Building Plans Included:
Owner/ Statement or License 077431
3 sets of Plans / Plot Plan
THE FOL19WWG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
— K yn Delay
Signature of Building Of icial 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« z
City of Northampton
s
Building Department
212 Main Street
Room 100"
,'� Northampton, MA 01060
phone 413 - 587 -1240 Fax 413- 587 -1272
.
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
)- 0 C
1.1 Propertv t` i A c3 C Lot Unit
L f �A ` 6 Zone, OverlayAistrict
i:fm5t, District CB District
SECTION -2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
260 [RLAPIC kd - (Or tFLC C) oa
Name (Print) Current ai ing A s: b
!-
Telephone
Signature
2.2 Authorized Agent:
Current Mailing Address:
Ate - Vau
Signature Telephone
SECTION 3 - ESTIMATED- CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only `
completed b permit applicant
1. Building % (a) Building Permit Fee
2. Electrical (6) Estimated Total Cost of
1 9 Tob
Construction from 6
3. Plumbing Z0 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) ° Check N umber , _j
This Section For Official Use Onl
Building Permit Number Date, Issued:
Signature:
Building Commissioner/Inspector 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
Lot Size
Frontage
Setbacks Front 7__
Side L: I R --- L i R: I
Rear I --
Building Height f
Bldg. Square Footage %
Open Space Footage — — %
(Lot area minus bldg & paved w�
par
# of Parking Spaces
Fill: a
volume &Location 1-- ,
A. Has a Special Permit /Variance /Finding A9er been issued for /on the site?
NO Q DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Re ' ry of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book i Pag and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0
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
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location: a
E. Will the construction activity disturb (clearing, grading, exc4yation, 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.
A
SECTION 5- DESCRIPTION-OF PROPOSED WORK (check all applicable)
New House Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [O] Other [O]
s
Brief De criFiol� of Proposed pk� T 1, `� W l rtv ) t�s
Work: _ *`► sr� * \i C�kGatG{ WA�,� C�aa�Sr ma �wst l`u y� 1�flbvh
Alteration of existing bedroom _jZ Yes No Adding new bedroom Yes _v No
Attached Narrative Renovating unfinished basement Yes tr No
Plans Attached Roll - Sheet
sa If riCeur ho s ON 1 il
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? Oe
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 - Td BE COMPLETED WHEN .
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PER
as Owner of the subject
property V i
hereby authorize - /" �(a� K A �
to act on my beh If, in all matters relative to work adthonzed by this building permit application.
Signature of Owner Date
I, l J t\ �� ', �, } �^ Q v" L ]L �` e (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 perjury.
A � c.
Print Name
Signature of Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Superv �1, t Not Applicable ❑
Name of License Holder �i n `�""1 Ic S T"' S
License Number
X13 "$ �ti A� , v � �n 44(112.
A Expiration D to
Signatur Telephone
Not Applicable ❑
Company Name i y� Registr do Number
3iZ �l WV& I FAQ , (�l l L
Address Expirati n ate
Telepho
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M'i.G.L. c. 1152, § 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 buildiq6ermit.
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 veriod shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to th uilding 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 requ' ed 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' Compens on) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts eral 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 responsi ' ity 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
l ?
The Commonwealth of Massachusetts
Department of Industrial Accidents
U Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov /dia
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers
APPUcant Information Please Print Lejibly
Name (Business/organization/Individual):. f (
Address:
City /State.(Zip: �b�►� � }: a % 0 Phone. #: 4% U-r— A.-M R
Are you an employer ?.Check the appropriate Type of project (required):. /
1. Q I am a employer with 4-. I am'a general contractor and I
employees (full and/or part time).
: have hired the sub- contractors 6. New construction
2. � I am a sole proprietor or partner- listed on the sheet: 7. � Remodeling ;
ship and have no epployees These sub - contractors have. 8. Q Demolition
. emplo yees_and have workers'
working for me in any capacity. -- -- - 9.
.Q Building addition
comp. mettran�P #. - .
[No workers comp: msuiaace 10 Electrical repairs or additions
required ] 5. � We are a corporation and its X - ep
- 3. EI I am a homeowner doing all work officers havexercised their 11 Plumbing repairs or additions
myself: [No workers' comp. right of exemption per MGL 12: [].Roof repairs
insurance required-] t P. 152, § 1(4); and we have no
CN
employees. o workers' 13.0 Other
.
comp. insuranc reg6ired -1 LJ
'Any applicant Shat checla box #.1 mast also fill out the section below showing theirworkers' compensation policy informatiott
t Homeowners who submit this at5davit.indicating they are doing all work and then hire outside contractors must submit a mew affidavit indicating such.
:Contractors that cheek this box must.attached an additional sbect showing the tame of the sulrconft=ors and state whedier or not +those entities have
employees. If the sub - contractors have employees, they must provide their work=s' comp.,policy number.
tam an employer that isproviding workers' compensation insurance for. ray employees Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site Address: City /Stxte/Zip:
Attach a copy of the workers' compensation policy declarafiou page•(showing the pghcy number. and expiration date).
Failure_ to secure coverage: as required uafiGr Section 25A'dfMGL'c: 152 cirri lead - to fiie imposition of ciimiQ 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 tiie violator: Be advised that a copy of this statement maybe forwarded to the Office of
InvesttQatons ofthcDIA for insiirancc`covera:re verification _ ::_.. _
cder the ahmand enahies o _
p p .fpe' 179' thaftheinformatraRprovrdednbave _c _aadrorrect._ _ _ -..
Si tire: - lb
� - MIA .
Phone #: -
_
Ojfzcial use only. Do not write hi this area, to be completed by city or town offic&l
City or Town: PermiitUcemse #
Issuing Authority (circle one):
J. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical Inspector 5. Plumbing Inspector
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
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
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
�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, 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 me.
Date
Address of work
location