17C-052 46 STRAWBERRY HILL BP -201 0 -1191
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C - 052 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 -1191
Project # JS- 2010- 001725
Est. Cost: $18000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEPHEN D ROSS 079160
Lot Size(sq. ft.): 2234628 Owner: LELLMAN JOSEPH E & MARTHA R
ZoningURA(10n1/ Ap plicant: STEPHEN D ROSS
AT: 46 STRAVv bERY HILL
Applicant Address: Phone: - - -- -Insurance:
36 SERVICE CENTER RD (413) 584 -1224 0 WC
NORTHAMPTONMA01060 ISSUED ON:6/25/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE SIDING
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: OjC 9— --
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
-ANY OF-ITS- _RULES AND RE • , „_ t : N .
1:444•4 Amp 4.1,444
Certificate of Occupancy anc / ignature:
P Y g
FeeType: Date Paid: Amount:
Building 6/25/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
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
zegulatinns The inspection p_roces&requires that the buildin . 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
— permits- in -conj unction 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, / ' J /9' 7`/+* L C_t_ 1 O 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 i ®C? j
.. : Date-- _.�_ _.
Address of work y 53
location raj
•
The Commonwealth of Massachusetts
Department of Industrial Accidents - '
m' —.=111--....m.-. - Office of Investigations •
. r �_� 600 Washington Street
' •- t Boston, MA 02111
mg ' www.mass.gov /dia
- Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/organization /Individual): e r b re'"? ' - ri ..s` _- I Su' /4 `e+-r..._
Address: 00 ,S & / -s ..t* g
City /State /Zip: Sp ri r tleId / m O I to y Phone #: 7.13.3- °
Are you an employer? Check the appropriate box: I
Type of project (required): i
1.0 I am a employer with 4. 0 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. ❑ Remodeling
ship and have. no e_::ployees These sub - contractors have g_ 0 Demao;it on
working for me in any capacity. employ' have workers'
g Y P t5' employees and 9. 0 Build1 g addition
[No workers' comp. insurance comp.- :nsutance.$.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I ate a iomeowaer- doing-a l- work- -- _ -ce_rsbave ^ -exercisedlhear T__- 1-1.- 0-- 1?lurubingrepairs 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.p Other Q 6c iris 04_46_
comp. insurance 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 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.
l am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information
Insurance Company Name:
A m iii . . .CoK fhv C e--
Pol # or Self-ins. Lic. #: 46 in 2 9 OO SsS 3 60 / 2 - °I 1 Expiration Date: ` ° //f
Job Site Address: y E Sirawberpv , // -Flo tr/1 City/State/Zip: / 6, --
Attach a copy of the workers' compensation p 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 fine
of up to $250.00 a day against the violator. Ele advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby semi under the pains and penalties of perjury that the information provided above_istrue t
_and-correc
Signature:
Date: 0
Phone #: 8 .Z - 6 ` a y7 -
Official use only. Do not write in this a rea, to be co by city or town offzciaL
City or Town: Permit/License #� ___
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other -
Contact Person: Phone #: