23D-043 (5) 1
- 1■V■SpZ )
'(
1
\ON� oo ?l lc,\\ND S � k )
0
II li
\Soc\ ))
1 LI i
9 x
P3 °C1 AN ?II "rr-
w .\\K\ kSnr- S :Arl 9/ 7-- L ta
ooh m� �� t
c)1\1,\.,\,vzsAs CNN\N\-,foixp fl\ 0
. ,„,\., s",r\m.y)0_,. -24)1\ \\,\., 60ANA ' DA00 p P\
" 6k-__Is \ .D \ =1 \ODN\tt\an N\K\ ),01\0 , 00\c\ cO.;AV\S
.pt 1 '' kmp Pr 1 (I- i ,4 mA,a
krqk1/4\77 ) V4N4S V7\ \c(e\ 0,,N
s ot1AM P 7 .
.-. `..d /fn1*
• n r•t IIlA54A[lt3lSttt -• _ —
_` /.
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
s`s`
Northampton, MA 01060
i'
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his /her construction sup,, :.: sor. 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 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 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
p
i
• •
a (ri12 o f � • il _1�
. � _ `��� � � . 1 _ -
E 51 csakcilnsrtla' —_
c 8 ro` . 7 , = i —
- d .• DEPARTMENT OP BUILDING INSPECTIONS 4
212 Main Strcet. ' Municipal Building
Northampton, Mass- 01060 r'
WORKER'S COMTENSATION ENSURANCE AVFIDAVfl
I, __A - - -- -- -----
cons •J permi ttcc)
with a principal place \ of�busi r nessfrrccssidence at: - ^
N ) , C) \ (L\ \ Y�3v \ ` \ ∎ • G �� () hone ') c2,1 r `l414
(s.t/ci ty /statdn p )
do hereby certify, under ttie.pains and penalties of perjury, :hat
•
( ) I am an employer providing the following worker's compensation cove age for my .
•
employees worming on this job:
(L s ram Comtzn'') (Pclic: Nu_ri - /..r) (r : Darr)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's comoen_sa on policies:
(Name of Con , . ^cior) (In :cane: ColnoanyfPoiic Nu:n c) (I'_ ?:pirduon Date)
(Na of Cono (insurance Compaav /Po!ic Nu ber) (LXDimtion Date) ,
(Name of Contractor) (Lasurance Company/Policy Number) (Expimdon Date)
•
(Name of Contractor) (Lnsuranca Comcany/PoLicy Numbr) (Expiration Dale) .
(nth :th± oc .1 fi- .caif nccc.rr to i>c?u iafocnvEoo pctuains to .11 cc o=---r-ors)
( I atn a sole proprietor and have no one worming for me.
( ) I am a home owner performing all the work myself.
o
NOTE: pie be wlrtt tt,,, ki�•ic bcmrb..vcn u axpIoy Dczom to do r>%r^ -- - === . ro r 1 r1 work on a dwd1 ^z of •
act t cca t h o 1 . , - - ' , K 1 . , - - ' , K ta i s wb c:12 the bornoow c raid= oc cc the crouoc , zpputtca:rl tb -t o L-c o'X c-=.. :.11y coaid. - c+i to be
cirploy - „rv'r, the wcakd: c p -atica Act (G il 52..=1(5)). a by a bomca ac fc a Goa or paznit rr_y cvidmcc t1:c
IeEp-I ctksc of ca c loy - coder ciao Worko Coco ,,o -.io,a Act._
I undcrtapd tba a copy of till, c tocoost may b. forwnvd.d to tb. Dop.rrmooa of I^A Acodcmd 015 0. of Lrralraoos for th.
cove c v"--if calico attd th_a Lilt-1'c to i«auc ovcrase „tvi. -- scctioc 2.5A of Ma- 157 eaa led to the i_ of mmiatl pea. thct
cocci:Linz of a floc of up to 51_500 .00 cnd/or ituprisoazoccd of up to ooc yr.--r and civil pcmltio in t ,c form or. Stop Work Ordcr and .
• S100.00 a thy tipin.a Inc.
— — - - - --
Fa<.w„y, =, .....tu..c only
a' \\ `g 6 Permit Number
Map:: __ Lot
S i tnatu • of Lict nscrlP rm t.c.c e - - - l .t-
•
SECTION 8 - CONSTRUCTION SERVICES a .
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : 1,� .� CS 0 1 y `c 1
\ \\ License Num er
0IS 1 �10A \.. , (j\V )� \ 61
d ` ,
A Expiration IDdt
-
*-c;\-e\
Signature Tele hone
.-
9�Registeced Elome'prorre Cont acto f t : t ;K W Not Applicable ❑
V., k k.,\c. .-. va • 4.)0\ Ih 1 �' \ L Z.is"
Company Name \ Registrati n Number
DX kc\ ' 11 \e ‘ "N O\-;c \ C7_006
Address , Expiration ate
Telephone 5' 1— .A4A
SECTION 10 WORKERS' 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 buildin permit.
Signed Affidavit Attached Yes No ❑
I 1; 2 ome O ?v ne> y � - p oi
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
r .
i
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑: Replacement Windows Alteration(s) Roofing Er
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [0 Siding [DJ Other
Brief D scriptipn of Prqiaos d � [`
Work: DV lio Mal c L1C� S'= � lys
Alteration of existing �jedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll Sheet
a.
s If NeW hot se =aria or..4ctdttiatr.to,oz rt ..
W . st>Inct�lous7rq.�cornp�ete th e �tlow�nq;
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? ,/
0 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 -r OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING. PERMIT
I, go" A" tvN L .. t - N - AF ' ' - r \ IC i +, , as Owner of the subject
property
hereby authorize ^ i^ ( ei h c9 (--\
to act on my behalf, i all ma ers relative to work aut rized by this building permit application.
4 ..� )) ) .K 1 e 9--
Si . tw wner Date
■p! A t V o , , as ewae Authorized
Age hereby declare t at the statements and information on the foregoing application are true and accurate, to the best of myfcno edge
anz belief.
Signed der the pains and penalties of perjury. '
1 w
Print , - .,
{ _,1 C.1 Al'
•`. A
Signature of Owne Agent Date
n
c
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 c 1,3 lsiJ Z 1� ,1 L %
1
Frontage —SZ�� ! `'�S(,NS I
Setbacks Front F-3;4-1 I
Side L: R: L~ R : 1 ' ,
Rear `
Building Height • V'
Bldg. Square Footage gC nil % FV,, _ I
Open Space Footage }}
(Lot area minus bldg & paved . , J '_` . l _ �" ` v l l
parking)
# of Parking Spaces
Fill: r r kiNd _ , .� o- 1
(volume & Location) ---- . '
A. Ha_ s a Special Permit /Variance /Finding ver 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 DON'T KNOW e YES Q
IF YES: enter Book Page; ry and /or Document #,,
B. Does the site contain a brook, body of water or wetlands? NO e DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission? '
Needs to be obtained Q Obtained Q Date Issued:
C. Do any signs exist on the property? YES Q NO e
IF YES, describe size, type and location: €
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
IF YES, describe size, type and location: 1
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 Q . NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
%
4
; ' r 5 D'ee k ite t iil '` . %' k ,
City of Northampton stat af' emii ; ° ¢ ` r
Building Department Ciro CUt[Dnv a , riru a '
212 Main Street sewer Set A i
al .Ili J
Room 100 Utt to e fi vaitabittty p - �� .... ..
Northampton; MA 01060 �F o-SetsofStr"t;ctura ( pfan ° "
phone 413 - 587 -1240 Fax 413 -587 -1272
p Pfot/StteTtans : - gr t- ' , ,.20%E- 4 07,*
O ther SPecr
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: Th is section; to be completed byroffice
1' Cd P Map Lot Untt
l v ` I ;
1 (� -, W 110, \> a� I \A� Zo Over : ,, i _ tstrtcf
V� - Elmt St �CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: ` __ —,. ,
- ,,`= lc.rvN,‘ �•.1c I n S' 1 149 .diz S t
� I No k ( l i Vno
Na Print) v ' Current Mailing Address: ` R n � `�
_ 83 n�
J (
� � _ __ Telephone
Signature
2.2 A thorized Agent: \\ \ \ i CA\ & 1 \k4 CNW ,.
Name Current Mailing Address:
ik\ •--- t-)7___S - Vf \
Signature Telephone
SECTION - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 1 190Q w (f0 (a) Building Permit Fee
i
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) W 0 N V Check' Number 3& 1/
This Section For Official Use Only
Building Permit Number. Isste.
issued:
Signature:
i
Building Commissioner /Inspector of Buildings Date
File # BP- 2005 -0615
APPLICANT /CONTACT PERSON MARK LANDY
ADDRESS/PHONE P 0 BOX 61 ASHFIELD (413) 628 -3203 Q
PROPERTY LOCATION 149 FEDERAL ST
MAP 23D PARCEL 043 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid f WINNi= 4 :1K&W , r.
Typeof Construction: CONSTRUCT ROOF OVER STEP •
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 077431
3 sets of Plans / Plot Plan
THE FOLLOWING 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 Co 'ssion
•re■0
/74
Signature of Building Official Date / y
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.
149 FEDERAL ST BP-2005-0615
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D - 043 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- 2005 -0615
Project # JS- 2005 -0822
Est Cost: $150n
. I.USI. �D 1 Jvv. 0
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANDY 077431
I. of Size(sa. ft 7971.4$ Owner: JENKINS BENJAMIN J & KATHERINE
Zoning: URB Applicant: MARK LANDY
AT: 149 FEDERAL ST
Applicant Address: Phone: Insurance:
P 0 BOX 61 (413) 628 -3203 0
ASHFIELDMA01330 -0061 ISSUED ON :11/24/04 0:00:00
TO PERFORM THE FOLLOWING WORK: CONSTRUCT ROOF OVER STEPS
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: Q 4 g S Q f� `,� ',�
Driveway Final: f j - GJ _ O t
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Insulation:
Final: Smoke: Final: OK t a�'?v
THIS PERMIT MAY BE REVOKED BY THE ,,TY OF NORTHAMPTON UPON VIOLA N OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupan ' /Aar Sgnature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 11/24/04 0:00:00 3611/3629 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo