17A-042 . BP- 2010 -0855
GIS #: COMMONWEALTH OF MASSACHUSETTS
Jgp 4ft 17A,, 04,E CITY OF NORTHAMPTON
AF
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 -0855
Project # JS- 2010- 001273
Est. Cost: $1500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin BOB THIBODO ROOFING & SIDING 065699
Lot Size(sg. ft.): 14984.64 Owner: MEEHAN RUSSELL & LUCY AND J A MEEHAN & H H MEEHAN
Zoning: URA(100) //RI Applicant. BOB THIBODO ROOFING & SIDING
AT. 192 BRIDGE RD
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527 -7663 () WC
NORTHAMPTON MA01 061 ISSUED ON :41512010 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE OVER 1 LAYER FRONT OF HOUSE
ONLY
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 4/5/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
City of Northampton
Building Departmentr�laCtltllt
212 Main Streete
Room 100 as
Northampton, MA 01060
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APPLICATION TO CONSTRUCT. ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address This section to be completed by office
Map tot Unit
r I Overlay District
Efrr1 St District CB District
.SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record
-- -- L - -- - --
Name (Print) — Current Mailing Address: C)j 6�
x 1 1 Telephone
Signature
2.2 Authorized , Age n t :
Nam Current Mailing Address: 0 ld(c, I
Signature Telephone
SECTION 3 - ESTIMATED' CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
com leted by ermit applicant
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) Its p Check Number ,
This Section For Official Use Oni
Date
Building Permit Number: 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
Side L - - R. 1,_.._.. _,_w L - ` R:
t
Rear
Building Height
Bldg. Square Footage %
Open Space Footage _ %
(Lot area minus bldg & paved
p arkin g)
# of Parking Spaces -- - "
Fill: t�
(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 0 Y
IF YES: enter Book = Page! and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW C) 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 NO
IF YES, describe size, type and location:
D �e £Fiore any proposed changes to or additions ofsigns n`tenoed`for tfie 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 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)
7 1 1
New House ❑ Addition [] Replacement Windows Alteration(s) ❑ Roofing
Or Doors 1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [o]
Brief Desc iption of Proposed
�� '
Work. '-_.11g "dl��li � �i��r l ita� 1"a r� Cs Ct0 QIe 0 a�f�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
i f t�ern�.I�oeise. acid' or_ Mit*rr€ `toe sfili c1`� orisirig.r o i pCete t�e:fii �uic � g:
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 sto ries?
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, L as Owner of the subject
property
hereby authorize c l \\ (, 11 bo
to act on my behalf, in all matters relative to work authorized by this building permit application.
o Ji�.r�nn "=r
Signs ure of Ow er OT4 — .�. Date j
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
--- 3 -7
Signature of Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES +
8.1 Licensed Construction Supervisor Not Applicable ❑
�
Name of License Holder : � s 1 1 d litl 1� -5 4 9
License Number
Address G i o Expiration Date �^
Signature Telephone
S.,Rectisterddy dame= IritpravetteTWIC itratitar x . ., _�, M K.,.y. .. Not Applicable ❑
Company Name Registration Number
��. F last- roc, P \t �} ,�� -��,
' Address f u �--} Expiration Date
Telephone
SE CTION 10- WORKE COMPENSATION INSURANCE AFFIDAVIT I (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 build g 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 consi dered 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.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
- Nort - ampton dinances Sate and 1 oca g aws azrd State ufMassaehusetts6eneral -Laws- Annotate .
Homeowner Signature
_ T
The Commonwealth of Massachusetts
Department oflndacstrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers
Applicant Information y— Please Print Legibly
Name ( Business /Organization/Individual): \ 1' e o-y
Address: '
City /State /Zip: Phone . #: S ° `16 C,
Are ou an employer? -Check the appropriate box: - - Type Ofpi-oject (required)_.
1 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
2.0 I am a sole proprietor or partner- listed on the attached sheet 7. Ej Remodeling
ship and have. a. emp loyees These sub - contractors have. .8. E3 Demolition
working' for me in any capacity. employees and have workers'
9. Building n addition
[No workers' Co insuran _. comp. ms uranrn _ _ Q..._
required:] 5. We are a corporation and its 10.0 Electrical repairs or additions
3. [] 1 -am a - horneo-wner- doing -A -work - - — __ _ - -2 cers ve Exer cisfd their_ - —11.E-Ir lumbing repairs or additions
myself. [No workers' co right of exemption per MGL
12. Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.}
* Any applicant -that checks box #I must also fill out the section below showing thew workers' compensation policy information.
t Homeowners who submit this affidavit. .indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
'Contractors 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 isproviding workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name CnZAK 14
Policy # or Self -ins. Lic. #: C)C) ( (, Vi\ e � tg Expiration Date: . X i
Job Site Address:- ' \k CityfState /Zip: ' �
ON
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 and/or one =year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a , ne
of up to $250.00 a day against the violator. 8e advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coveraoe verification.
I do hereby certify under the pains andpenalties ofperjury that the u:formation prgvided above ty true -and correcZ - -_ -__
Signature:
Phone #: (01 S -
Offcial use only. Do not write &T this area, to be completed by city or town oriciaL
City or Town: Permi tUcense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrica
6. Other Inspector 5. Plumbing Inspector
Contact Person: Phone #:
HOME OWNER EXEMPTION ACKNOWLEDG>EMEN't
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
x egiilations Thy inPCtion n �cs s requires that the building_department be call to
inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before noun 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
__pe wits- in- conjunction._to. the uilding..p- ermit.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.
Address of work
location