32C-340 (6) L FPF aTMEINT GP BUITu_D�G ItiSPF=OtiS
iNSP�CTCR 212 Main Strut • Municipal Euilding --
Nonbampton, MA 01060
T:nom tr n� ��rz EX NU�TION ACKNOWLEDGEMENT
L i u i _ � ,� v+-�-
Fjwh�oovvns f Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
er construction sup-: :nor. The state defines "Homeowner" as, ";?erson(s)
a parcel on which he!she resides or intends to be, a one or hvo family
ttached 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 I
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 SUP erS.S,; to he 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 bacl;f'iII).
sonotube holes (before pour) a rough bu7dina inspection (before work is
co-acealed) inrsulation-inspection (if reu.uired)a-nd_aT'Inal_huildine.insnectio.n. 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 ran-beInspectEd.-
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- y
Date
Address of work
location
The Commonwealth of 1Ylassachusetts
r Department of Industrial-4ccidents
M
1 0fflice 0 Investz-a-ions
600 W ash ingron Street
Boston,A14 02111
www.mass.a ov/dia
Workers" Compensation Insurance Affiaati-it: Builders,Contractors/Electricians/PIumbers
ADDHcant Information Please Print LesibIv
f
NaMe(B siness/Orzmizadon/IndIvidual):
?address:
City/State/Zip: Phone.,-:
Are you an employer?Check the appropriate box:
Type of project(required)
i_❑ I am a employer with 4. ❑ 1 am a_general contractor and I
employees(full and/or part-time)_
have hired the sub-contractors 6. -New construction
2 n r^-r T> listed on the attached sheet 1. n R Pmode 7T g
J u 1 am a sole proprietor or partner-
I ship and have To;ploy ees These sub-and have have g_ ❑Demolition
working for me in any capacity. employees and have workers'
� iNo workers'cow.�sluance com .insmo.nce.*` �
9. 17 Building addition
COME).
required] S_ ❑ We are a corporation and its 10.❑Electrical repairs or additions
❑ I am a homeowner doing all work o racers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.[v o o f rep airs
insurance required]t c. 152, §1(4), and we have no
employees. [No workers' 1'-❑Other
comp.insurance reed-]
- ---"may aPp I=n ===ooz rJ sour auo nil out the section oeiow sncwmg t es work-°s'carnpen anon policy information.-- --
Homeowners who subrzat this affidavit indicating they are doing all wont and then hire outside contractors must submit a new affidavit indicating sucit.
*Contractors that check this box must.aitached an additional sheet showing the name of the subcontractors and stare whether or not those enddes have
e nplovees. If the srb-corur;i=rs.have ernpiove.s,they must provide their work-=s'comp.policy number.
lam an employer that isproviding workers'compensation insurance for my employees Below is thepolfcy andjob sue
information.
Insurance Co=any Name:
Policy#or Self-ins. Lic. Expiration Date:
Job Site Address: City/Stafe;Zip:
Attach a cony of the workers' compensation policy declaration pace(showing the policy number and expiration date).
Failure to sec n-e coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1500.00 and/or one-year imprisonment;as well as civil penalties in the form of-a STOP WORK ORDER and a Hne
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 DLA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct-
Date: _
Phone#7
LOther e oruy. DO not write to this area, to be completed by circ or town offciaL
Town: Permit'License
thority(circle one):
f Health 2.Building Department City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
rson: Phone
1
5
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
t
Name of License Holder: � O
License Number
e ny s 4 As+k co,46 L IAA C�
Address Expira oon Date
SignatA Telephone
9.Registered Home Im rovement`Contractor: Not Applicable ❑
l IS1 `��
Company Nam Registration Number
<--� )=t::� Ash���0—� P�- --)- 0 ?
Address Expiration Date
0 ll, C-) 4nn 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 bu ing permit.
Signed Affidavit Attached Yes....... 4 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-vear 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 actins 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
r
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors 71
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[0] Other[E:]
Brief D �tio n Proposed ,
Work: -e
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
r
hereby authorize
to act pn my behalf all ma ears relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized
Agent herd6y declar` hat the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Nam
��'V,7s:7� , t , Q � �— I=Q— On
Signature o Owner/Agent 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 filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R:. L:_ . R
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
varking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES Q
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 0 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 dish-irh(r-.learing, gnarling,Pxravation, 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.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/S1eTT--s""
.� it
Other 5pe "n ''
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
IJ
SECTION 1 -SITE INFORMATION
Thi secti6pTl Vie;corripl0ed by-o•ice
1.1 Property Address: .Map L lJUnit___'
Zone Overlay District
Z� Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
t
Nam �(Pri»ti1.,�
—; C
\ urrent Mailing Address:
tC✓t— ph e
Signature
2.2 Authorized Agent:
6 � � e
Na a(Print) Current ailing Address:
Signatu Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit fee
2. Electrical (b)'EstimatedTotal 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:
_._ Date
Building Commissioner//Inspector ofBw mgs
BP-2008-0522
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catel4ory BUILDING PERMIT
Permit# BP-2008-0522
Project# JS-2008-000789
Est. Cost: $6200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Robert Thibodo 118441
Lot Size(sq. ft.): 6185.52 Owner: DION DONALD R
Zoning: URC Applicant: Robert Thibodo
AT. 120 HAWLEY ST
Applicant Address: Phone: Insurance:
P O Box 201 (413) 586-0391
NORTHAMPTON MAO 1061 ISSUED ON.
TO PERFORM THE FOLLOWING WORK:RESHINGLE OVER ONE LAYER
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 11/20/2007 0:00:00 $25.00689
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo