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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(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 ❑
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 ❑ Addition ❑ Replacement Windows Alteration(s) Roofing 0
Or Doors D
Accessory Bldg. 0 Demolition ❑ New Signs [O] Decks [[j Siding[D] Other[0]
Brief Description of Proposed
Work: Demo 18ft sect of round garage shop wall,dig and pour new footing and foundation wall,re-frame,sheath and side new wall section,sure-up framing as needed,add skylight,add outlets,insulate and re-roof.
Alteration of existing bedroom Yes x No Adding new bedroom Yes x No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
6a.If New house and or addition to existing housing, complete the following:
a. Use of ilding:One Family Two Family Other
b. Number of roo • in each family unit: Number of Bathrooms
c. Is there a garage attac -d?
d. Proposed Square footage of 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. •nstruction 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 `•
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
l (/71i wner/Authorized
Agent hereby declare that the statements and information on the foregoing application and accurate,to y knowledge
and belief.
Signed under the pains and penalties of perjury.
a .
•rintl Nall,
i � H ` 15
Signature o • ner/Agent Date
< ! Department use only
City of Northampton Status of Permit:
: NOV i 4 2013
wilding Department Curb Cut/Driveway Permit
I 212 Main Street Sewer/Septic Availability
Electric, Pium:.r a $a9ctions
Ncrtha:,, ,;, r.A 1 ut-0 Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
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
2-7 )) 14 A) A) GT Map Lot Unit
L e 3S, A k 01 05-
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWN SHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Karen E.Carter 223 Main St; Leeds MA 01053
Name(Print) Current Mailing Address: 413-221-7419
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 15000 (a)Building Permit Fee
2. Electrical 1,000 (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) 16,000 Check Number
• This Section For Official Use Only
Building Permit Number: I sssuu
ed:
Signature: / t /�y
B ding Commissioner/Inspector of Buildings Date
223 MAIN ST BP-2014-0613
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10B-090 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-2014-0613
Project# JS-2014-001033
Est. Cost: $16000.00
Fee: $80.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 18687.24 Owner: CARTER KAREN E&BETSY FERBER
Zoning: URB(100)/WP(58)/ Applicant: KAREN CARTER
AT: 223 MAIN ST
Applicant Address: Phone: Insurance:
223 MAIN ST (413) 221-7419
LEEDSMA01053 ISSUED ON:11/14/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR GARAGE
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 11/14/2013 0:00:00 $80.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner