31A-026 . .
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 proceas 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
- - - - -- - -per -nits- 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
1.; Office of Investigations
®
.7.-4-
600 Washington Street
Boston, MA 02111 .
• www.mass g oV /din
-Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/IndividuaI): Y I U. \ VP .�,(_ 1 CA
Address: .� I 1 J .D(/ f f r�'
City /State/Zip:`} , Ili U , (-) 1( ) (rya Phone. #: 3-,2 C-) - /6 3 /
Are you an employer? Check the appropriate box: Type of project (required): / .,'
1.0 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. 0 Remodeling
ship anti have no loyees These sub - contractors have. 8. 0 Demoiiuon
working for me in an capacity. employees and have workers'
Y P ty. # . 9. 0 Building addition
[No workers' Comp. insurance comp._ntsuram e.
required:] 5. E We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am-a lomeowaer- doing- all-vork 9 Ee ve exercised ir__. -1:-1:1-- Plumbing repairs or additions
myself. [No workers' comp. rift of exemption per MGL 12. J 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 -iffiriavit.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 worker' comp. policy number.
Iam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: -
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 51500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fun
of up to $250.00 a day against the violator. Ile 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 under - : atiisTand . aloes ofperjury that the information provided above true_andcorrect___-
Signature: i 7 Date. // 4' �
Phone #: - r 3
` Official use 04. Do not wale in this area; to be comp -kited 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
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 1 1 1•ti1 PS C 1 (( (S ,P, L/ Cr L/
— /
-- - - Eicer,3oNum or
3 1 c S , tlike i //. „ l)/ O
Address Expi of tion ate
Signature Telephone
9:= Registered. Ho a lmproveine ontractor� , "F , r -' . .- > Not Applicable ❑
1/711�ic /yam /7,
Company a me Registration Number
3// /LJ(l - Ii �i 4 0/ 0
Address Expirat(on to
' /c) ) f Telephone ...3= 3/
SECTION, 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6»
Workers Compensation Ins ranee affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance o e building permit.
Signed Affidavit Attached Yes No ❑
The_current_exemption for "homeowners "was extended to include Owner 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 referencVto 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
_ -_- s- General - Laws- Annotated.
`' o amp on or. rnarices; _ a _e . _6 • , __. ,, # � - -o _ .
Homeowner Signature
r
a
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Ur Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [[] Siding [D] Other [0]
d
/ er,d
Brief Description of Proposed J
o
Work: Al' po CSC \\ Ir o
Alteration of existing bedroom Yes,, ) tlo Adding new bedroom Yes No
Attached Narrative . Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
5a. If Newt Ouse and 61`:addifiO3't,tt eicisting ]'toiiiihe;=GOf'iplkte the -folioWin :
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, c- Le- . �SG. , as Owner of the subject
property
hereby authorize ` /. ' CS C..-
to act on my behal e a r ative to . uthorized by this building permit application.
p
Signature of Owner Date // - / ,'
I, K . F. cC , C , as Owner /Authorized
Agent hereby declare that the statements a information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and pe -Ries of perjury.
Print Name „- /
Signature of •- n- i• gent 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 tilled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side
Rear —....
Building Height
Bldg. Square Footage F ? %
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 N O YES
IF YES, date issued::
IF YES: Was the permit recorded at e Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page' .._._ .. _._ and /or Document ft,
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 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 0 NO
IF YES, describe size, type and location:
- "D. - Are there any ro`osedchan es to or a rtrons o si ns intendedfor tie property YES 0 NO
P P g g - P P Y?
IF YES, describe size, type and location:
E. - Will the construction activity disturb (clearing, gradi , 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.
a <
City of Northampton
Building Department 1rd&Ir►
212 Main Street e�����,
Room 100
— N rthampton, -MA 01060 - - .
phone 413 - 587 -1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, - RENOVATE. -OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION i
L. U
1.1 Property Address:
This section to be completed by office
- c
e;. Fret k_ 1 1 J Map " Lot Unit
10 - 1 1 l i Zone ` Overlay District
EIm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner oord:
_�'S C t
Name (Print) Current Mailing Ad ress:
Ur ;1 --1 -'- Telephone
Si nature
2.2 Authorized Agent:
1.4 1 1.11 Ke_.s c - 3 1 1
Name (Print) /j Current Mailing Address:
/ /l( kp , 1,AAA ' • /6 /
Signature Telephone
SECTION 3 - ESTIMATED•CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
1-)00 06
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) 16)0 J 00 Check Number Q �
This Section For Official lise Only
Date
Building Permit Number: Issued:
Signature:
1 ' Budding Commissioner /Inspector of Buildings Date
t . BP- 2010 -0553
Gls #: COMMONWEALTH OF MASSACHUSETTS
rmiouictic 3=iA -026 y 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 -0553
Proiect # JS- 2010 - 000777
Est. Cost: $1000.00
Fee: $35 00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KIM RESCIA 022464
L Sice(sq. ft.). 7579.44 Owner: RESCIA RICHARD R & HELEN C
Zoning: URA(100)/ Applicant: KIM RESCIA
AT: 43 FRANKLIN ST
Applicant Address: Phone: Insurance:
311 Locust St (413) 584 -5816
FLORENCEMA01062 ISSUED ON:11/20/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE GARAGE 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 11/20/2009 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- constriction 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
ermits 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 -
1, 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
Date
Address of work
location
. •
The Commonwealth ofgassachusetts
Department of Industrial Accidents • , ,
Office of Investigation§ , •
600 Washington Street
Boston, MA 02111 . . .
vvidia www.mass o • '
, . • '2,
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
, .
Applicant Information . Please Print LevIlv
1
Name pusineseorg-4thiationandividuaD: X ) 1/ fe,sc i
. , .
• . Address: 3 i (
. i
CitY/Sta . - r - c3re titi .) 11
ll 1 ‘. 1.e .#: ,) / --
Es. 3 i -
\/
Are you an employer? Check the appropriatehox: • , •'Type Of 'project (required):
• 1.0 I am a employer with. , 4.. 0 1 am a general contractor and I \
0 New construction
employees (fall and/or part-time).* have hired the sub-contractors
2.. I atri a sole proprietor or partner- listed on the:attached sheet: 1. R,einodeling -
These sub-contractors have
• ship and have rin, :■-loye •8. 0 Deinolition •
working forme in any capacity. ePAZIPYCP1--_ •have wOrkers'
9 ET lliildifig atliditi .
[N® %workers' comp. insurance .
r _._, rdquirc:d•l ' •
• 5. 0 We are a corporation and its 10.i Electrical repairs or additions 3. U I am a homeowner doing all work officers brie4xerosed their 11.o Plumbing repairs or additions
myself [No workers' comp. • right of exemption per MGL r-r • -
12.Li Roof repairs . -
insurance required..] f • - ,c. 152, §1(4), and we have no • ., .
employees. [No workers' 13.0 Other r •
comp insuranc required.}. - -
*Any applicant -that checks box #1most also fill out the section belowshowMg their-Workers cornparsation policy information;
1. Homeowneri who subrnit this affrdaVitincricatiag they are doing all war* and then hire outside contraCtors must submit anew affidavit indicating such.
:Contractors that chick this box must attached an additional sheet showing the name of the sulcantiactors and state whether or notthose entities have
eMployees lithe sub-contractorshaVe aap1oyeer4 they must provide their workers' comp. policynumber.
• lam an employer that ispropiding }porkers' compensation insurance for my einplOyees. Below is the policy and job site
information. . • • . -
Insurance Company Name:
. .
• - .
Policy # or Self-ins. Lic. # Expiration Date: - . • ,
. .
Job Sim Address: • '• City/State/Zip:'
. .
.Attach a copy of the Tvor4rs'coroPglisalion PoiicY declaration Md-(showing the PialiCY •!10-!..apiration date).
. . . .
Failure to secure coverage as reqUitilliiiicleY.SeCir 2.5A 152 can lead to the imposition of penalties of a
fate up to $ 1,5oa00 and/or one-year finprisonmen4 as well as civil penalties in the form of a STOP W0p..1c-Oft.DEB. and a &_e
of up to S250.00 a day against the violator. Be advised - that a copy this statement may be forwarded to rue Of
TiVertiiiiiiiiis - 6 ;:;;T:':' veri ' _ ' - ---
ans.. . iesaltiei ofperjuty4Itai the infirMatiOniroyidetta :, ....
... „ .
,
Sienatui:e:- - :/// / - . : 7 .. ____. ,
Phone ifi: 7 " "? e. /Yr - / - - • •
. - Official are ortly. Do not write iii this tu-ea, to be completed by city Or to)PnairiciaL
City or Town: -
• Pexmit/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 #:
• -
•
_ —
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 1 \ i " �j C 1 /\ C J L Z47//_ �o 1
License Number
3/ ( /.� G J • Z i
Address Expira o n Da
Signature Telephone
1
rat / ./ 1 Z e f a 3 z o / sr- 3 (
9., Registe ` ,.Heat .ImDro o en " on rac x .. � , ' '�� ,. ; ; Not Applicable ❑
(/. , F ) e _s c_ i CL 1 k4 t 1 1 1 ' a
Company Name 1 J � ^ Registrati Number
3/' ) /if�tA St ` 1 — I v NACU j j) i al i Z
Address Expiratio D e
Telephone 3 /,C-- 3 /
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 Ye 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 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
ii ) e.R.Li ft v (..)---- (/i
fk1 42._ CA...) tab, ge,,,,,...1„....
SECTION 5- DESCRIPTION! OF PROPOSED WORK (check all applicable) p„,q-, ck ci b ^ ` �1
L'-' , T1., i At tAcP�6 F404/c.
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing 0
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding [D] Other [0]
Brief Description of Proposei i
Work:'} tit y '-.... t 1 ( it 4 • t+ I - 0 cliC
Alteration of existing bedroom Yes �1 No Adding new bedroom Yes
Attached Narrative Renovating unfinished basement Yes '' No
Plans Attached Roll - Sheet
sa `i t4iit hol s iiiia additrol ti iits`ti iii iiii q. i3iiia fe t ie` 1160 p:
a. Use of building : One Family •.i 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 •
I, 1 Al lit , as Owner of the subject
property
hereby authorize /1 I re S( 4_
to act o ii- : - half, i atte►: , ve to work authorized by this building permit application.
LL
Signature of Owner Date
I, t 111,1A, e S ( / r , as Owner /Authorized
Agent here y declare that the statements and reformation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and pen�? of perjury.
K / �' 's0 a
Print Name
-° /7 ./ ' 1 2 7- (
_ Signature of Owner • g t Dab.
0 ", i
Section 4. ZONING A ll Information Must Be Completed. Permit Can Be Denied Due To Inco fete Jnforma � . ,
#. ''s / 3
Existing Proposed Require b y 7ming
This column tfteftfOrcl in by',', -,..„ i
Building Department 4I ''" ti ,,
Lot Size
Frontage
I `
Setbacks Front i i ( I l
__
Side L: L— _ 1 R:i ? L:= a R: ! 3
Rear I 1 i i
Building Height = r
Bldg. Square Footage = = % = = 1 i
Open Space Footage %
(Lot area minus bldg & paved i ? j _/. ..�_ p
parking)
# of Parking Spaces ---- --
Fill:
(volume & Location) I
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:! i
IF YES: Was the permit recorded at the Registry of Deeds?
NO .J DONT KNOW 0 YES 0
f i 1
IF YES: enter Book I , Page i and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 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: ..ma _....._.a._..
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
IF YES, describe size, type and location: i
µ
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.
(= Ne
i, ` • s ity of Northampton = ...,1. h , k „At : ilding Department s , = w - °� 7 . , t
tbi)f e a2 Main Street � ... - T- a
ey'"n Room 100 e �<
`. __ Northampton, MA 01060
- phone 413 - 587 -1240 Fax 413- 587 -1272 �'
■
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 Lot Unit
Zone Overlay Drstrict
Li 4- ii(o, o∎ 4,U
[\4,1_,., 1.).61,... Elm St District CB D
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
` � � 61 es c i 'L__ ./3 - 7 4 - rc; X- i S
Name (Print) CurreMaiyn Ad dress: /11
■
Alair 1,7/ * Telephone
Signature
2.2 Author'zed Aqent: ��
1 ' I IM K e e ( 3/ ��Gl.l S
Name (Print) ,(, h Current Mailing Address:
--"\
—7/7 , - J / 3Z(*) '' f
Signature / \ Telephone
SECTION 3 - ''ESTI ATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 42.5..L. (a) Building Permit Fee
ioeo
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) _ / L) 0 0 uv Check Number ....-- 17/ 5
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File # BP- 2011 -0789
APPLICANT /CONTACT PERSON KIM RESCIA
ADDRESS /PHONE 311 Locust St FLORENCE (413) 320 -1831 0
PROPERTY LOCATION 43 FRANKLIN ST
MAP 31A PARCEL 026 001 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 a ` —�✓
Fee Paid a ,t7 J
Typeof Construction: OPEN 3' WALL TO MOVE FRIDGE BACK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 022464
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN O ATION 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
emolit' ' Delay
c
e of B ilding ficial 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.
w '
43 FRANKLIN ST BP- 2011 -0789
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 026 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP- 2011 -0789
Project # JS- 2011 - 001303
Est. Cost: $1000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KIM RESCIA 022464
Lot Size(sq. ft.): 7579.44 Owner: RESCIA RICHARD R & HELEN C
Zoning: URA(100)/ Applicant: KIM RESCIA
AT: 43 FRANKLIN ST
Applicant Address: Phone: Insurance:
311 Locust St (413) 320 -1831 0
FLORENCEMA01062 ISSUED ON:4/6/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:OPEN 3' WALL TO MOVE FRIDGE BACK
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 4/6/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
43 FRANKLIN ST BP-2011-0789
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 026 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP- 2011 -0789
Project # JS- 2011- 001303
Est. Cost: $1000.00 •
•
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:. KIM RESCIA 022464
Lot Size(sq. ft.): 7579.44 Owner: RESCIA RICHARD R & HELEN C
Zo : U U n i 17 :0':i 4pp/ie. l t: - KIM PFSCIA
AT: 43 FRANKLIN ST
Applicant Address: Phone: Insurance:
311 Locust St (413) 320 -1831 0
FLORENCEMA01062 ISSUED ON: 4/6/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:OPEN 3' WALL TO MOVE FRIDGE BACK
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:0 ' 9 — l c (j^N;
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation: i ll . f
Final: Smoke: Final: (K � -,Ag-1 t C /`t N..
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAATION OF
ANY OF ITS RULES AND RE ONS. 1 / ‘�,�K/�'►✓
Certificate of Occupant sig nat ure:
FeeType: Date Pail : Amount:
Building 4/6/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck – Building Commissioner