24A-239 (3) •
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/footines (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
,
. “
. The Commonwealth of Massachusetts
Department of Indus Acidents .
Z '"="'911:%■ !". Office of Investigations •
• 600 Washington Street
• --[:.t— Z Boston, MA 02111
7 , www.mass.gov/dia
, • __..,
.-•
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information •, Please Print Legibly
..: ,
Name (Busines.i/Organizaiion/IndividnaD: SPs Cief-TP----V C.". , ( --e-3 . ...
. , .
Address: t 3 S - LAA-A-1.44 S'j(' , •. • -
City/State/Zip: &I■liV1t# Phone.#: 4P A :r- i ' 11 ---- -
Are you an employer? Check the appropriate box: • Type of project (required): /
1. En am a employer with t 4• 0 I am a general contractor and I
6. 0 New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on theattached sheet.. 7. arzemodeling
2. 0 I am a sole proprietor or partner-
These sub-contractors have.
ship and have no i>loyees .8. 0 Demolition
envloyees and have workers' . ..... -
working for me in any capacity. 9: El litml■cMg aUclitiOn.
#
[Igo workexe comp. Mstiance .. co.stniice.
required.] , 5. 0 We are a corpora 10.DElectrical repairs or additions
and its
3. 0 I am a homeovvner doing all work officers havexercised their . 11.0 Pluming repairs or additions
.t b •
myself [No workers' comp. right of exemption per MGL
12.0 Roof repairs . -
insurance requirecLJ t ' • c. 152, § 1(4), and we have no • ,
U
employees. [No workers' • 13. Other
comp. insurance required.} - - •
*Any applicant -that checks box #I must also fill out the section below showihg their woricers' compensation policy informatiOn.
t Homeowneri who submit thii afradaVit indicating they are doing all work and then hire outside vontraCtors must submit a new affidavit indicating such. • IContractors that check this box must attached an additional sheet showing the name of the subcontractors and State whetheror notlhose entities have
employees. If the sub-contraitorshaVe employeet, they must provide their workers comp polidy number. . .
.1am an employer that i s providing workers' compensation insurance for my einplbyees. Below is the policyand job site
information n.
& a . k '
Insurance Company Name:
Policy # or Self-ins. Lic. #: ORA) ?)1 (..:714.A.M.i--Sirtt-t.--- Expiration Date: - 2- 1 I .
Job Site Address : ta C P --- 0 11 - hif if.; Ntb1 City/Stafz/ZiP:'
Attach a copy of the workers' compensation policy declaration page (showing the policy number andcapira.tion date).
__.
Failure to secure coverage as requited uncter Seetiiiii'25A c. 152 can lead to the iiirPoSitiari Of rirninai 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 yiolator. Be advised That a copy of this statement may be forwarded to the Office of
Iiifeitiiiitioni theDIA. - fol= eciVe"-Aie'ireileiiii:'
_... :.:
I la hereby certi , n =,' e parnsand penalties el that the infatnationprovididaboveittrue_aniLeor;ect.L__
. .
Signature: ' Da
15 ip - • .
• : • '
Phone #: L I 6 c,-.,,l— tl,t1r. • • • - - • •
Official use only. Do not write in this atia, to be edinplPtPd by city Or town officiaL
•
City or Town: . Permit/License #
- -- - -
Issuing Authority (circle one):
.1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical 5. Plumbing Inspector
6. Other .
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 4 NA-4 14- C � S a q
License Number
�3 S M-A-41 &'_ S LP 10 t 1
Addr .s Expiration Date
Signa i re Telephone
9. ome lmpro# etrmeritCoii ract+biKE,,u nE._u ., WW , ,_ a. r: Not Applicable ❑
C C ,> , f . C.e — a Gif) 9
Company Name Registration Nu ber
Address I t Expiratin Date
Telephone p ✓n) ° — I - 1 - 7 't
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 building permit.
Signed Affidavit Attached Yes LY No ❑
nt4lioinelthvneribrein
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 1083.5.1.
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 0 ____ Replacement Windows Alteration(s) Roofing
Or Doors IMr
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [0]
Brief Description of Proposed 14 0 L1+ ADA Uri Tv $ Cc: Cf AI N T
Work: kg Lo K.(T O ck ftIJ C A,N,4t ,zS/(.004 cGwf -5 d 140„..0 rotettif , 4A,�i .4: L...i.Owm)
Alteration of existing bedroom Yes ✓ No Adding new bedroom / Yes No
Attached Narrative Renovating unfinished basement Yes t.-- No
Plans Attached Roll - Sheet
sa fi gtfra t s'.i ;o a .. a.V .. h+o l nitt - em iT h iii.. " r t
a. Use of building : One Family ✓ Two Family Other
b. Number of rooms in each family unit: ' Number of Bathrooms Z.
c. Is there a garage attached? � iT-S
d. Proposed Square footage of new construction. 14P5- Dimensions
e. Number of stories? 1
f. Method of heating? C AS Add 0- 0 Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction '-- F
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 t./
SECTION Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, .) OA) , Po , as Owner of the subject
property
hereb uthorize 4� S A c
to a in my beh f, in all afters relative to work authorize by b t�ing permit application.
r
ti t h0((U
Signature of Owner ..-^''� Date
✓I --_ 4' , `'t(,i—va-cti , as Owner /Authorized
Agent hereby declare that the statements and informatiorkon 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 /
Signature of • ner /Agent Da -
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
i 1i 1
Lot Size I -
r
Frontage l ` .
Setbacks Front 1 l 1
Side Li 2 R: ? L:4 i R:'., i f
Rear = 111.1010, `
/
Building Height 1 !
Bldg. Square Footage L t% 1 1 i F
Open Space Footage I %
(Lot area minus bldg & paved i s ..._.—
parking)
# of Parking Spaces - -- --°
Fill: .�,�.
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW er YES 0
IF YES, date issued:; I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I Pagel i and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO er DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location: I
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:
E. Will the construction activity disturb (Gearing, grading, ex vation, 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.
City of Northampton . . o � � - �
Building Department
212 Main Street �,
Room 100
,-
Northampton, MA 01060
' 1 ,, 'IA 2. 2U 413- 587 -1240 Fax 413- 587 -1272 .: vA = �� ,
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
(5 IWa- A- 'i`�U(l- Ma p Lot Unit
Y
A L't,Vv- -e .CA---- r IM,r- zone Overlay D►stnct
Elm"St Districf";'" " CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 O ner of Recce ,---..........____
ot� i4� �
- r1 CL
Na a rint) Current Telephone S 12 Mailing Address:
6 U 1G
Sigel$ ture
2.2 Authorized Agent:
-.) d kA- r tA • Ar Cld -mil 5 3 5 - L,).A i—(- ) S0 -DI Li-ti?
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION: COST
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building Fb all) (a) Building Permit Fee
2. Electrical '1 (b) Estimated Total Cost of
1 (1U Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) L t SOS
5. Fire Protection
6. Total= (1 +2 +3 +4 +5)
1 S C heck Numbe p7Y 3
This Section For Official Use Only
���'�(�/ Date
Bui dingg ermd Number. Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0952
APPLICANT /CONTACT PERSON SACKREY CONSTRUCTION
ADDRESS /PHONE 83 SOUTH MAIN ST SUNDERLAND (413) 665 -9995 0
PROPERTY LOCATION 65 ROE AVE
MAP 24A PARCEL 240 001 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 1 7 a /./ -�/C�
Fee Paid / e
Typeof Construction: REMODEL KITCHEN & ADD NEW BATH & INSTALL REPLACEMENT WINDOWS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 040714
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN_F9RMATION 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
Demolition Delay
Signature of Building 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.
•
65RQEAV .; , BP- 2010 -0952
GIS #: COMMONWEALTH OF MASSACHUSETTS
?- 24 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 -0952
Project # JS- 2010- 001412
Est. Cost: $75000.00
Fee: $450.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SACKREY CONSTRUCTION 040714
Lot Size(sq. ft.): 18425.88 Owner: PEPPER JON C
Zoning: URA(100)/ Applicant: SACKREY CONSTRUCTION
AT: 65 ROE AVE
Applicant Address: Phone: Insurance:
83 SOUTH MAIN ST (413) 665 -9995 () Workers
Compensation
SUNDERLANDMA01375 ISSUED ON:4/29/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN & ADD NEW BATH &
INSTALL REPLACEMENT WINDOWS
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:
FeeTvpe: Date Paid: Amount:
Building 4/29/2010 0:00:00 $450.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
t
.
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
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, L4 2./ ,L�'V understand the above.
(Home owner /resident signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date 6 -- / - d 00
Address of work �
location L i " � � " ` /. r i m / e : ,r.
76 fil Q /97,4 /in 0 /0 l;
s.
40^_ The Commonwealth of Massachusetts
Department of Industrial Accidents
f , --, Office bf Investigations
600 Washington Street
--:— ---= Boston, MA 02111
•`'= www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /EIectricians /Plumbers
Applicant Information Please Print Legibly •
Name ( Business /Organization/Individual):
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (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
listed on the attached sheet. 7. El Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in capacity. employees and have workers'
g any P tY 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. ❑ 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.E 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.
1 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: i
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City /State /Zip:
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 h reby certify undeer the pains and penalties of perjury that the information provided above is true and correct.
l ariattire: i -g 2p1,J,{ . efait...../ Date: co •- / Oe- 7'
Phone #: 6//3 ) i - " 0 45
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):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
at
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Registered" Home Improvement Contractor .., _ , , Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG.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 building permit.
Signed Affidavit Attached Yes ❑ No ❑
Z a 8. „e
11. — H Owner, :2 in ption
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 Windows Alteration(s) D Roofing n
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [DJ Decks [C7 Siding [DI Other [0]
VVVVV r eef Descr .tion of Proposed i /
Work: Ara ./,, f A" ......41......411'M . w- i —,e _ a% - : r ' `B d,L • r• , r! , .
V / / / / ��
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
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? 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
1, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner_._ ___ _ __- _ __._ _ _ _ ____ _ _ Date
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.
Print Nam
✓i , , y �_ �� .
Signature of Owner /Agent f / Date
A
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
Rear
Building Height
Bldg. Square Footage
Open Space Footage °
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 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 (3 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES t NO 0
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 YWS, th ®n 2 Northampton Storm Water Manaaemnnt Permit from the DPW is required.
L
Departp ent use onty
City of Northampton �tatuso f Permlt
\ s ', , , \ : \ c 2 °, Brailding Department Curb utID ewa Per
212 Main Street Si n re r l S ep#�"Av3iiabtldy
y0� �" Room 100 1NateriWell�vai�atsfFit
\-\ , —
\ Ngirtha ` pton, MA 01060 Tinto Sets €Strt�ctrra(Plans "'. �
phone 4.1 3- 587 ?40 Fax 413- 587 -1272 Piat/S►te PI
Oth er Spea
APP LICATION 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 Lo Unit
�~ � /�'r� � O � g Zone Overlay District
/Yo�'f a 7fl74/1/
U fO(�
E lm - District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
�d r" Aa / f . sac rt.�
Name (Print) Current Ma ling Addres } it
�,� /j Telephone
Signature (i741,"0 '1-i. fz - c ' / 3
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
/ Building 6i (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
- ' Construction from (6)
3. Plumbing Building Permit' Fee
'0'
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3+ 4 + 5) Check ,Number /1)°72' 35.----
This Section For Official : Use Oniy
Issued
Building Permit Number: Date
Signature:
Building Commissioner /Inspector of Buildings Date
h
•
BP- 2009 -1005
GIS #: COMMONWEALTH OF MASSACHUSETTS
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- 2009 -1005
Project # JS- 2009 - 001448
Est. Cost: $9800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10280.16 Owner: RYAN BARBARA J TRUSTEE
Zoning: URA(100)/ Applicant: RYAN BARBARA J TRUSTEE
AT: 54 PILGRIM DR
Applicant Address: Phone: Insurance:
54 PILGRIM DR
NORTHAMPTONMA01060 ISSUED ON: 6/1/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 6/1/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo