38A-004 (3) , . .
AKTICIE 23
TERMINATioN
23.,0 l . _ c.iiiitiactor shall;
la i tie adjudged bankrupt,
cosi persistently or repeatedly refuse or fail, except in ease s. winery eist ,'d `,10
::sided. to supply enough proper1:) skilled vi 6fkit01 it pries imitoOd is its; neltinii
disregard laws, ordinances. rules, 1 c(AhttiioIs
tt...ithoritis having jurisdiction over the WORK or
st or guilty of material violation of this Agreement,
then the tits:ter shall be entitled, upon seven (7)days prior notice, unless the (loran:icier sl
such violation during said. seven (7)day period, to terminate this Agreement and take possession ol tile 'site
and au t materials n:id eintnent thereon and finish the WORK hy visitiliesser methoo libii rier or
expedient.
ARTICLE 24
GOVERNING t,AW, FililisliiY.
lilt's Corr:;::: - he construed and enforced in accoraeee ',,itit the u!:) lay;
Commo:1 t it' sotissechusetta without giving effect to the consilitts, eir choice iLi' iao. ft. I Liic
and -,..ht1;: have the titiiiitte; of a sealed instrument,
link A exect:ted on the day and year first written
Contractor
CHAGNION4BLititDIN(i ii.. K iviiittitEt,i
.. 7 ___,„.....
itsf*restdenti
Owner
fliia : '-:-/:''';''
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Copyrght C 2011 Ch8gr::,n Building 4 RefrIC LLC.:
City of Northampton
z Massachusetts
uxx
DEPARTMENT OF BUILDING INSPECTIONS
W7-1 4 212 Main Street • Municipal Building��
Northampton, MA 01060 Nr
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 any 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 backfilf, 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 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
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
v Office of Investigations
600 Washington Street
a
,�.... Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): 4 , efiti c//c-/>t/Le 27 ii'
Address: 9( 5.ckr3ttciy, , -
City /State /Zip: 4 - ) CXO Phone #: 47(3-Ai 7_ K
Are you an employer? Check t e appropriate box: Type of project (required):
1. II 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 attached sheet. 7. emodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
g Y P h' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions
myself. [No workers' comp. 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 #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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: /5-2-f , 1- C c
Policy # or Self -ins. Lic. #: Expiration Date: o7 /0\
Job Site Address: 2 Ai i � S per � City/State /Zip: /Ur144 7 .c
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 $1,500.00 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 the violator. Be 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 certify u r the pa n and penalties of perjury that the information provided above is true and correct.
r 5/� /
Signature: _ � � Date: 5/3/0
Phone #: / 3' (75 -67e
Official use only. Do not write in this area, to be completed by city or town official
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 #:
•
SECTION 8 - CONSTRUCTION SERVICES
a
8.1 Licensed Construction Supervisor: / Not Applicable 0
Name of License Holder : 6 y 4 - C 6 (/' i'VNC
/ License Number
yf � ; tt-4f3 ld j-r P — � A b y / 9 0/0 / /
Address Expiration Date
Signature / Telephone
KRegis eyed` oirie nproveme'ntC no tra tor. ; %, .. t Not Applicable ❑
x[8757
Company Name Registration Number
C//4&11vL la /a to .
Address / Expiration D
9j 5/ /3' L T.A r McVey C14 Telephone 9 5 �
SECTION 1 0- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G L c 152, § 25C(6)) v` ,
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 I Y No ❑
® - 1t1 Q wrier elm ion
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 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
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
•
•
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) •.
New House ❑ Addition ❑ Replacement W_ allows Alteration(s) n Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [l ] Decks [0 Siding Rat Other [0]
Brief Description of Proposed
Work: //.I24 /UM/ bet/ firmed' £J/1// i pl /I,'eGV lk � 0Lim
Alteration of existing bedroom Yes 1 Adding new bedroom Yes /No
Attached Narrative Renovating unfinished basement Yes �o
Plans Attached Roll - Sheet
sal��ew�tiouse�ara ®;hor�addifi`on to existing €hous�nq compete "theyfoll`owing:
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? /t.(4 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 OWNERAUTFIORIZATION TD BEGOMPI_ETED _WHEN f
ri. 3r
OWNERS AGENT OR CONTRACTOR.APPLIESFOR BUILDING PERMIT
I, Lr 0/3/ 6)0t01:4) (bc (c) '' - fry(/ , as Owner of the subject
property /l
hereby authorize J C/ 46/uC -
to act on my behalf, in all matters rela hie to work authorized by this building permi application.
see r - 7/-M/ 5 /
Signature of Owner t Date
, as Owner /Authorized
Agent hereby declafre 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.
(3 ` T cfel /' a
Print Name
Signature o Owner /A.- , Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Inco pletq Information '
Existing Proposed Requir by' oni 7
This co to filled in by * `
Build' Dep itt
Lot Size 1
w ��
Frontage
Setbacks Front ?
Side LL----I R:` i L . ! R:! I I i I
Rear 1 =
Building Height , = I
t
Bldg. Square Footage i 1 1 i %
Open Space Footage %
(Lot area minus bldg & paved I S i I
parking)
# of Parking Spaces 1 I I i !
Fill:
11
(volume & Location) t I
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I
I Page; and /or Document #1
B. Does the site contain a brook, body of water or wetlands? NO el DONT KNOW 0 YES 0
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 0 NO er
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES (3 NO
IF YES, describe size, type and location: 1 I
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Yt *a �` 34. "l..P
z i - $, D ,a e01t use sin
• City of Northampton Sta u � i
t �, ,, '-'
; uilding Department "C. a r .. �+a rt -' •
212 Main Street Sewert ep 9-:;--,,Y,.,-„,„„-,; bi Ity, -
Room 100 a el � etty
41 3 + orthampton, MA 0106 t } . � � .
6
- -'; phon 413- 587 -1240 Fax 413 - 587 -1272 P�� S e ans
Ot Sp eci fy _ �� . . , , r` , . ,
.�Y�...,..: ^' ,., e , . .,.�..r�,�a"'� � ;r?"Stl, } °tea a' �. .��;� ,x, ' :.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE,INFORMATION,.
Thissection to be- completed by office
1.1 Property Address: y (- {� ■ ,: � a ,, ,,` i w � x *, , � ' t u -,
_
' U 3 V 1 1 V 1'i.�r� 3 `", ; LOt `'' ' : U nl � �
� a` � t'+
C. was, -x ,17-1,..„„,„:72.1-7„,1,, - . -, d '." 'a' . ., , 4 s - . `> ` `r..
.{./� M(/ /� / /, �^ /j� ' {'y //� //'. ZOIIe . ,i, .O Yerl a4Dlst icct 4 cc ?. ,?t�� A'k r:
NC 1 4 4' •{� . " i " 1 - 0' c 0 ,, .a �' a ar ; 4 ,ax ,-, i= :` k .
"k .:5' A .,.,`` t .
...Elm St. District. , ,.' CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AG
2.1 Owner of Record:
h 6/3 rx-a) ,L r D e u ' 'r CU7l�i` - r y r I3 u711f f� �4P / r f /4 -'
Name ( int) Current Ma Address
Telephone
Signature ,
2.2 Authorized Agent:
G� s .. C6 9i 5 , I e eci ; /11/1-el /y, A0 O/
Name (Print)/ Current Mailing Address:
r asp 7fS
Signature Telephone 3
SECTION 3 :,:ESTIMATED CON CO
Item Estimated Cost (Dollars) to be Official Use Only ,
completed by permit applicant
1. Building NC ( a ) Building P ermit Fee
(p00
2. Electrical (b) Total ,Cost of
.,w`" Construction from (6) ..; _
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) Che '
ck Number '� ..
This Section For Official Use Only -
P ermit N umber. Date ., Buildin
Building Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
•
File # BP- 2012 -0129 '
APPLICANT /CONTACT PERSON GARY J CHAGNON
ADDRESS/PHONE 91 STOCKBRIDGE ST HADLEY (413) 259 -6785
PROPERTY LOCATION 2 BURTS PIT RD
MAP 38A PARCEL 004 001 ZONE URB(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 • •
Typeof Construction: INSTALL SIDING & 2 NEW WINDOWS fru5q
New Construction j
Non Structural interior renovations Akin ��
Addition to Existing ',
Accessory Structure 5
Building Plans Included: z5GLu t
Owner/ Statement or License 060175
3 sets of Plans / Plot Plan
THE FOLL NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION PRESENTED:
pproved 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
Si g na . of Buildi g 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.
2 BURTS PIT RD BP- 2012 -0129
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38A - 004 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit # BP- 2012 -0129
Project # JS- 2012 - 000191
Est. Cost: $6000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GARY J CHAGNON 060175
Lot Size(sq. ft.): 11412.72 Owner: PUSHKIN MICHAEL A LIVING TRUST
Zoning: URB(100)/ Applicant: GARY J CHAGNON
AT: 2 BURTS PIT RD
Applicant Address: Phone: Insurance:
91 STOCKBRIDGE ST (413) 259 - 6785 WC
HADLEYMA01035 ISSUED ON:8/4/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL SIDING & 2 NEW WINDOWS - MUST BE
ENERGY STAR - SAVE STICKER
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 8/4/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner