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f Office of Consumer Affairs & Busidess Regulation
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e it xpiration: 4/24/2014 DBA
D.J. B TLER CONST
DANIEL BUTLER
20 RILEY SWITCH ROAD
PHI ;IPSTON, MA 01331 Undersecretary k;
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a '' ''3 , ' ,;!VMS achusctts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 51355
DANIEL J BUTLER ' 1 6. , i j
20 RILEY SWITCH RD
PHILLIPSTON, MA 01331
,.. — � . Expiration: 10/9/2012
.. (ommissilm + Tr#: 3345
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DANIEL J BUTLER 04 -91. 6074 j
.
DBA D J BUTLER CONSTRUCTION ... -
20 RILEY SWITCH RD
PHILLIPSTON, MA 01331 1 I 3 1 t 53- 8306/2113
978- 790 -7011 DATE 2 l
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IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 -S (2001/08) Certificate #63981
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City of Northampton
„,;,,,k4:44 Massachusetts r . ;;
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= DEPARTMENT OF BUILDING INSPECTIONS „ ? '
, 212 Mai Street • Municipal Building 0 - .,
smr � . Northampton, MA 01060 ss /ey,,,,
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
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
3 Office of Investigations
I. Z ..._ '�' 600 Washington Street w
�,. . = A' Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
pplicant Information Please Print Legibly
aisle ( Business /Organization/Individual): ) T IR v T GS- Coe" ST' _
.ddress: ,2..o RI 1.ey, `a P.,b
,ity /State /Zip : 7 k, t t ( iuw d 9A- a i 3� 1 Phone #: 9 2 8 - 7Z '70 //
re you an employer? Check the appropriate box: Type of project (required):
❑ I am a employer with 4. 0 I am a general contractor and I
employees (full and /or part-time).* have hired the sub - contractors 6. El New construction
� I am a sole proprietor or p artner- listed on the attached sheet. . 7. El Remodeling
p p
ship and have no employees These sub - contractors have 8. (1 Demolition
working for me in any capacity. employees and have workers' 9. ri Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. (l We are a corporation and its 10.0 Electrical repairs or additions
q ]
3. [ I am a homeowner doing all work officers have exercised their 1 L(l 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. C Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I 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:
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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Siiature: C C- Date: Nag./ _2 d%
Phone #:
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 #:
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : P P 1414- ) "u Vie.. ' \.
License Number
R 11.��jsu k -rck 3,D 0/33/ 35`5"'
Address
6 ' Expiration Date
C/ r
7d 70/
Signature Telephone / /11,2/2,
9.:Re istered.Norne l'm rcivemericGoiitractor ; y, , Z Y Not Applicable ❑
`CAM if -S P„TL L
Company Name . Registration Number
?d. l (Teti RD /l`Sllo "7
Address . Expiration Date
a l l i � 64t/ jM or 3 Telephone C 7 ' 79.0--7411
' 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 ❑ No ❑
1 1
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
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I 1 Fl rL C I to ',(, A b nc500A) gert4 ,6r1,t >sr-'
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WiA)GOVJ.
:CTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)' ,, ,
:w House n Addition n Replacement doves Alteration(s) ' 1 Roofing
.� �� g Or Doors L�
ccessory Bldg [ J Demolition New Signs [D] Decks [ E ' Siding [CDI Othe , -J
. • •
,rief Description of Proposed
Vork: zNC�.. tom, 1.tTt�iurC. wACL Cc /�,it � ,♦ + •
-i•-• - i L. cle ...0.‘ __ IOW & \Iteration of existing bedroom Yes No Adding new bedroom No
Mttached Narrative Renovating unfinished basement Yes N. r ! i` / ' 6 ' ()
Plans Attached Roll - Sheet
n., - u .- ,.,��.,- _, �, -e-X-- .,�, s_� -t- =scxr .,* n . � d i I �Y�
6a t Newhouse � and or addition isting housing, 7cornpiete the "�I"t/► , -4, ,
a. Use of building : One Family Two Family Other • ` 4■+ *`
b. Number of rooms in each family unit: Number of Bathrooms
A`
•
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 CONTRACT ° ,APPLIES.FOR BUILDING PERMIT :`
I, Ad h(( rvI W�.�' 4 4 ,' , as Owner of the subject
property
hereby authorize % Ao..; it- 'S - 6,./i - ‘ e Z • I) •T T\.<: rapt/Sr
( to act on my ehalf all ma s relative to work authorized by this building permit application.
\ a , t
Sig caner Date /VO// 2 oZp
1, D > e L- ) 3,Tbe K , 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 er the pains and penalties of perjury.
2. wjr T` 13aflci
Print Name
,� �, ,, - �.. /vale ..,D- ,74
Signature of Ow /Agent Date
•
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by coning
This column to be filled in 4tt
Building Department J+t *-•J
��' 3g.
Lot Size 9 • ?
Frontage
Setbacks Front �3
Side L: R: i /
Rear 5y . --
Building Height
asTo)
Bldg. Square Footage Oat %
Open Space Footage _
(Lot area minus bldg & paved -73-4
parking)
t
# 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 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 Page, I and /or Document #'
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW (3 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 NO
YES, describe size, type and location:
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 (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.
®c s ., '''',.,-.,1.-.;;-:,-.1'11't x D ep a rtm e n t use only g x a
�rII LL
CEIV�� City of Northampton s ooP ^ i ; {' � 1 ;.
Building Department Curb CutfiDnyeway Perrhlt 4 �x f ' A , ,
2
212 Main Street S Availabit � " '� ' r ,. a �
2012 212
100 Wat k 4 u
DEPT OF orthampton, MA 01060 TWOS etemfStructural Plan " �i - - 4!,''', - , - :,=',4 i'
NORTHAMPTON ING 1NSPE , � t t � �`'� , � � 7- z 7
rON MA 01 4 3 -587 -1240 Fax 413- 587 -1272 Pi Si e lans =,
•
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 byoffice
1 N 0 RTI. ST' Map t Lot Unit
n
s
Zone Overlay Di .0 . , �
Eirit St: District ' , c , ist ric t
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 O er of Record:
�; %a AA el4 � Na J1 nnt) Current Mailing Address:
SignatuA Telephone
2.2 Authorized Agent:
DA 1c1.'� 11u Ao RkLet(S. i t ?h,I,i.rPsr , . 4
Name (Print) Current Mailing Address:
6) 4- -..` „/, 't78- 7/0 _70// rill”
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
- clod Construction from (6)
3. Plumbing uilding Permit F
; B e.
1 ' 3 1 3 4 4 '
4. Mechanical (HVAC)
5. Fire Protection
C1 ( . 16_. Total =(1+2+3 + 4 + 5) Check Number . .0 S
This Section For Official Use Only
Date ..
Building Permit Number: Issued:
Si nature: c ' ' . 1,46,—.4,,,0 ' a 2 i . /NF R,t �y 6l
g
Building Commissionerllnspector of Bu � � �J
Dat
117 NORTH ST BP- 2013 -0520
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 178 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INTERIOR DEMOLITION BUILDING PERMIT
Permit # BP- 2013 -0520
Project # JS- 2013- 000839
Est. Cost: $39200.00
Fee: $235.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DANIEL J BUTLER
Lot Size(sq. ft.): 9670.32 Owner: BASAL MOHAMMED
Zoning: URC(99)/ Applicant: DANIEL J BUTLER
AT: 117 NORTH ST
Applicant Address: Phone: Insurance:
20 RILEY SWITCH RD (978) 790 -7011
PHI LLI PSTON MA01331 ISSUED ON:11/2/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: INTERIOR DEMO ONLY
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 11/2/2012 0:00:00 $235.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner