23C-102 (5) ,
BP-2008-1092
GIS#: _ COMMONWEALTH OF MASSACHUSETTS
itihe:_ 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-2008-1092
Project# JS-2008-001616
Est. Cost: $2500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10018.80 Owner: SAWICKI STANLEY J JR&HEIDI S
Zoning: URB Applicant: SAWICKI STANLEY J JR & HEIDI S
AT: 565 RIVERSIDE DR
Applicant Address: Phone: Insurance:
565 RIVERSIDE DR (413) 586-1425 O
FLORENCEMA01062 ISSUED ON:6/5/2008 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 6/5/2008 0:00:00 $25.004696
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
f--. Department use only
��J>�,.:.City of Northampton Status of Permit:
-\V �� \ .v wilding Department Curb Cut/Drivewway Permit
// \ `� \212 Main Street Sewer/Septic Ava ability
/ l
V--, - A _ Room 100 WaterlWeltAvailability
5 2. Northampton, MA 01060 Two Sets Of Structural Plans
3\. ‘` phone 41:51587-\240 Fax 413-587-1272 PIot/Sife�Plans
y 'N.. ;rKS Other Specify
AAP tId"SA�ION,'O CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
■
SECTION SITE-INFORMATION l
1
This section to be completed by office
1.1 Property Address:
54,5 RIVERSIDE" DR Map, Lot Unit
F1oQ6nce, rylf 0/6bZ Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Slpn/eY 4 i-h ioi Srlw:cxi , JR . ,51x5- � ieees/ve OR, Fnrence / 0/66z
Name(Print) Curr clint M ling Address:
1111 SrtWICY/L / £2d d( L1'1 (‘4f, Telephone
Signature
2.2 Authorized Agent:
Name(Pent) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS {
I
Item I Estimated Cost(Dollars)to be Official Use Only
completed by permit aoolicant
1. Building ) F� I (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 >,Q�±J�
6. Total=(1 +2+3+4+6) Check Number -L7/L_
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
Building Commisioner/Inpestor-or 6uflamgs Date
.
Section 4. ZONING I All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
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Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size ._._ . .._ti.. __ .._... �-.._ . _.�:_
Frontage _ _.._-._.. ._._.,.,. : _ —._._.. _____,... -.-.. .__ .,.._..;
Setbacks Front
Side L._.,_.__ R: L:.._.._.: R: ___..__w : _.__:
Rear 1 - _ _.
Building Height ._,`
Bldg. Square Footage % I ______
Open Space Footage ______ ._. /o !I I —
o
(Lot area minus bldg&paved
oaridn_) .
#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:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES __ _,..._
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 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 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 0 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 YES,then a Northampton Storm Water Management Permit from the DPW is required.
I
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House I I Addition l l Replacement Windows Alteration(s) 1 ' Roofing
�— Or Doors D
Accessory Bldg. t Demolition 1 New Signs [�J Decks [Q Siding[p i Other jp]
IBrief Description of Proposed
Work: REPLACE ROOF
Alteration of existing bedroom Yes / No Adding new bedroom Yes No /
Attached Narrative Renovating unfinished basement Yes V No
Flans Attached Roil -Sheet
6a.'
a if NeW house and ar addition:to existina`housiria.comafete the-foI(dwina:
a Use of building : One Family Twc 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 Wccdstoves 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 SE COMPEELtLF WHEN
OWNERS-AGENT OR CONTRACTOR APPLIES FOR SU1LDINGPERMIT
i , as Owner of the subject
property
hereby authorize
to act cn my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I I 5/ /eq J 5 uicrii Jr , as Owner/Authorized
Agent herby declare that the statements and information on the for going application are true and accurate. to the best of my knowledge
and belief.
Signed under the pains and penalties of pe fury.
._- --
rant dame V$20�
SIcna,ur_of Owner/Acent are
SECTION 8-CONSTRUCTION SERVICES I
3.1 Licensed Construction Suoeriis=or: / Not Applicable ❑
Name of License Holder:
License Number
;ddress - Expiration Date
Signature Telephone
G.Registered Home lmorovergent Cgirtregtat:_._. �_. Not Applicable ❑
:omoanv Name Registration Number
.ddress Expiration Date
Telephone
ECTION 10-WORKERS'COMPENSATION•INSURANCE AFFIDAVIT ENF.G L.c.152,§=25C(6j) I
'crkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit.
gned Affidavit Attached Yes ❑ 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.CNIR 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 Ofticial.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 under signed"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 42"'4J -.-0 ' `� `
--� The Commonwealth of,1assacnttsetzs
Department U./Industrial_4 cciderzs
- G;1 e oI; esti arcrzs cf .
600 Washington Street
Boston, MA 02111
WWW.mass.gov/dia
Workers' Compensation Insurance Affdavit: Builders/Contractors/Electricians`Plss:hers
Applicant Information Please Print Leaibly-
Name (Business,%Or_aniation;Tndividual):
Address:
City'State/Zip: Phone r:
Are you an employer?Check the appropriate box: Type of project(required): I
4. I am a general contractor and I
1.❑ I am a employer with 0 �
6. �New consn-uction
employees (full and/or part-time).* have hired the sub contractors
2.0 I am a sole proprietor or parcter- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working. forme in an capacity. employees and have workers'
Y 9. 0 Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. D We are a corporation and its 10.0 Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
1 ,myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] - c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
j comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Conn-actors that check this box must attached an additional sheet showing the narre of the sub-contractors and state whether or not those entities have
employees. If the sub-contactors have errmloyees,they must provide their workers'corn.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 Na'*-tie:
Policy 4 or Self-ins.Lic. 4: 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 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 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 d hereby certify under the pains and penalties of perjury that the information provided above is true and correct
signature: ,-5/�C�'K .-� for/I't.. • 11%2, Date:
Phone 4:
il Oil
7cial use only. Do not write in this area, to be completed by city or town officiaL I
City or Town: PermitLicense 4 I
Issuing Authority (circle one):
il
1.Beard of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector Plumbing Inspector
6. Other
i Contact Person: Phone
HOME OWNER EXEMPTION ACIOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CIM1R 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
-2..A-44 4-'4. 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