The URL can be used to link to this page

25A-075 City of Northampton + fa'j Massachusetts " .. t q DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building " "+ Northampton, MA 01060 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 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 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 ' Office of Investigations er if . , : . 600 Washington Street t�,` Boston, MA 02111 fit' -y = www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): IM j tj 5;0'f A r J fve _ 5 Address: 3 ,c Pervtn i , c.J/r j City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. 7 I am a emp1 w' h ' 4. ❑ I am a general contractor and 1 employees full /or part-time).* have hired the sub - contractors 6. [� New construction listed on the attached sheet. 7. El Remodeling 2. Li I am a sole proprietor or partner ship and have no employees These sub - contractors have 8. n Demolition working for me in any capacity. employees and have workers' 9. n Building addition [No workers' comp. insurance comp. insurance.t required.] 5. n We are a corporation and its 10.1 Electrical repairs or additions 3. n I am a homeowner doing all work officers have exercised their 11.n Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.11 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.�Other1t 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: /� / y' c f _ Policy # or Self -ins. Lic. #: 44/4 c 3 r XS ?... Expiration Date: ` /` e) / Job Site Address: �'"'r �c7 ��/ �"G' 41,/_6' City /State /Zip: , 4 t- 4 H o � Attach a copy of the workers' compens policy declaration page (showing the policy number and elpiration 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 under the pain ndpenalties of perjury that the information provided above is true and correct. Signatur . Date: ' 2_ ' e J 11 ' Phone : �K"(.) 3J 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 8.1 Licensed Construction Supervisor: / Not Applicable ❑ Name of License Holders � a7 f) � " A ) , 5 q License Number Address Expiration Date �_ — O - 77 Y Signe ture Telephone 9. Registered Home Improvement Contractor Not Applicable ❑ Company Name c—' Registration Number Address Expiration Date Telephone by 920 2 2 9/ ,/ SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M. G. L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit ust be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi permit. Signed Affidavit Attached Yes No ❑ 11. Home Owner Exemption 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 1 I Addition n Replacement Windows Alteration(s) I 1 Roofing Or Doors I] Accessory Bldg. 1 1 Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [0] [ Brief Description of P� sed ., Work: �/a r �fYC/ A /i 3 ,0 4.0,450112r) f /ta p)i 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 , 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 state : is and ormation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. izti /✓ /2/ Print Name y 1 / C r1/ `�-- Si atu e of Owner/Agent Date Property Address: (7 / (% r'e 4j/e Contractor /l j Name: //d4 s,5 S G4,4 ie ( t�� Address: S —9 s City, State: Phone: Property Owner / Name: (/) (/ /G i 1/ 6" Sid )7 Address: — - 'oo , -?/9-c-- - C - = — — - — — • City, State: / � % Z; , e t6z1 1, < (contractor) attest and affirm that the building I intend to insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit.____ Contractor signature i Date 4 • 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 DON'T KNOW 0 YES 0 IF YES, date issued: YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW Q YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT 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 Q 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 Q 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 Q NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only.` City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Sep ewer /Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structura Plans phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans =! " Oth er Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEM OLISH 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 District Eim St. District CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: Telephone Signature 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 1. Building (a) Building Permit Fee 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) Check Number This Section For Offic Use Only Date Building Permit Number'.' Issued: Signature: Building Commissioner /Inspector of Buildings Date cri ri Tilq L7f Nnrtt�2imptnni , ai9ttssttrftusrtts ,.t * w ` c , , 4 ) i , , ''., , ' > DEPARTMENT OF BUILDING INSPECTIONS �( � �, 212 Main SLreeL • Municipal Building f � s kti �� Northampton, MA 01060 L 11 BUILDING PERMIT FEES Phone: (413) 587 -1240 BUILDING COMMISSIONER Effective July 21, 2008 Fax: (413) 587 -1272 DEMOLITION $ 20.00 ACCESSORY STRUCTURE $ 35.00 PRINCIPAL BUILDING — Residential $200.00 PRINCIPAL BUILDING - Commercial *NEW CONSTRUCTION $ .50 per square foot for 1 floor .30 " " " 2nd floor .20 " " " Yz floors, attic, basement, garage STRUCTURAL ALTERATIONS IN ALL USE GROUPS $6.00 per thousand dollars of estimated cost or fraction thereof, with a minimum fee of $55.00 $25.00 WOODBURNING STOVE *NEW ACCESSORY STRUCTURES one hundred twenty (120) square feet and over $ .20 per square foot with a minimum fee of $25.00 *NEW ACCESSORY STRUCTURES under one hundred twenty (120) square feet $25.00 per inspection *SWIMMING POOLS $30.00 for above ground $60.00 for in- ground *SIGNS & AWNINGS $30.00 *DECKS $50.00 REPLACEMENT WINDOWS $35.00 SIDING & ROOFING Residential $35.00 per structure Commercial $55.00 min. per structure OR $61K of estimated cost TENTS $25.00 *ZONING REQUEST FORMS $15.00 (includes home occupation registration) . REISSUE OF LOST PERMIT $25.00 CERTIFICATE OF ANNUAL INSP. $100.00 (minimum) Temporary Certificate of Occupancy $25.00 PERMITS REQUIRING ONLY 1 (1) INSPECTION WILL BE A MINIMUM OF $25.00; ALL OTHERS WILL HAVE A $50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE City of Northampton AND SUBMITTED, WITH THE COMPLETED PERMIT APPLICATION, TO THE OFFICE OF THE BUILDING INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL FEE. !! NO CASH - CHECKS OR MONEY ORDERS ONLY !! * Filing deadline is 12:00 pm (noon) on Wednesday. __ Department use only p b (` City of Northampton Status of Permit: r" = - 7 Building Department Curb Cut/Driveway Permit 12 Main Street Sewer /SepticAvailability I I 5 Room 100 WaterNVell Availability i L _ Nort ampton, MA 01060 Two Sets of Structural Plans DE, , r NO RTHAMF ' OF BUiLi 143eari , 3 -5 7 -1240 Fax 413- 587 -1272 Plot/Site �, MA 07060 — - Other Specify 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 C - � l Map Lot Unit N 1 � H* f () O Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: V. 3 2C 5 N ... 59 Co o f, aE p Name Print (Print) Current Mailing Address: 3. 50 7� —L Telephone 3 , ` / p O �/ r Signature f 0 7 2.2 Authorized Agent: ICS( - r r ✓►e s S ✓Yl A s 1 St M4 Name (Prin Current Mailing Address: 27gY Signatur: Telephone SE ON 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building DO (a) Building Permit Fee �1 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) Check Number This Section For Official Use Only Date Building Permit Number: Issued: • Signature: � IPI Building Commissioner /Inspector of Buildings Date 59 COOLIDGE AVE BP- 2012 -1164 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25A - 075 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- 2012 -1164 Project # JS- 2012- 001987 Est. Cost: $2100.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN PERRIER 105319 Lot Size(sq. ft.): 5314.32 Owner: BRESNITZ VIVIAN Zoning: URB(100)/ Applicant: JOHN PERRIER AT: 59 COOLIDGE AVE Applicant Address: Phone: Insurance: 59 EAST MAIN ST (860) 930 -7794 STAFFORD SPRINGSCT06076 ISSUED ON:6/25/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: Perimeter wrap Basement insulate pipes 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 6/25/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner