35-106 (3) a C fr1 �:ix�:.J �? �L?'it? .?'sTJ1:li► N '° i/^
E)EP�FT1v_'_',T OF BUILDING UN SPEGT:ONS
212 Main Street 0 Municipal E uildins
WSP C T 0 P
Nortb,Lmptnn, MA 01060
iiv iXTI v ►TNrLID LYLtJ-D'T7Irlki s OL7'NnWt.FD ;FA4FNT
The State of Massachusetts allows the homeowner the right under 780CMR 7108.3.4to act as �,isl-Ler construction sup:_ -isor. The state defines "Homeowner" as, "Pwho owns a parcel on which he/she resides or intends to be, a one or two famdwelling, attached or detached structures accessory to such use and/or farm sperson_who constructs more than one home in a two-year period shall not be
home owner."
The building-department for the City of Northampton wants any per son(s)who seek to
use the home owner exemption, to a4. as their own construction supe:z:so; 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 back ill).
so-notube holes (before oour), a rough building inspection(before work is
concealed-).insulation insDection (if required.)and_a-rh al_buld na 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 occupancv
until the work can he inspected._
If the homeowner hires other trades to perform work(electrical, plumbing&gas) the
homeowner will be responsible to rake 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.
Dare
Address of work
location
The Commonwealth ofAIassachusers
Jepa,~<meni of Industrial A ccidents
O ace oflnvesrigaz-ions
600 TT-ashin- on Street
- % Boston, YL4 02III
;;
www.mass.gov/dia
Workers' Compensation Insurance Aida-,it: Builders/ContractorslEIectriciaas/PIumbers
ADalicant Information Please Print Legibly-
-Name C3usiness/Orzaniza on/Individual): ACaSa..-
Address:
City/State/Zip: Phone.-#,' N/5) ;z6 a—aa-Y6
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4• ❑ I am a general contractor and I
� Ioyees (l ill and/or part-time)-
have hired the sub-contractors 6. ❑New construction
?. T- listed an*fie attached shee� 7. ►�Remode i g
am a sore proprietor or partaer-
ship and have no employ ees These sub--on=ctors have g• �✓ Lzmo icon I
to ees and have work.'
working for me m any capacity. Y 9. FI BuiIdin--addition
! �j'0 w.�.r'sei�'-o=..insurance
�t�r�•��:ilve.'f Jill �
required.] 5- ❑ We are a corporation and its 10.[`Electrical repairs or additions
:-❑ I am a uoneowner doing all work ofizcers have exercised their I I.Y`Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL L.❑Roof repairs
in.ctnaice required.]t C. 152, §1(4),and we have no
employees. [No workers' 13.7 Other
comp.insurance required.]
a p-!Ivan an—.s ooz r,1 mixt aso nil out the seeaon oeiow s wmQ theff workcs'ca -- ---
rnp=s=on poiicv mforn3=
'Homeowners who submit this affidavit indica z they are doins aD work and fnen hie outside contractors musts 'umit a new amdavit indirat at such.
Contractors that chests this box must attached an additional sheet showin,the name of the subcontractors and state whetter or,not those eatn7es have
employees. rf the sub-contractors have empiovees,they must provide their wor3ccrs'comp.Policy nuIItee.
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/�7ip:
Attach a copy of the worriers' compensation policy declaration pane(showing the policy number and expiration date)_
Failure to secure cove:age_as required under Section 15A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1.500-00 and/or one-year izziprisonment, as well as civil penalties in the form of-a STOP WORK ORDER and a ne
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
In vesti_ations of the DLA for ms-,irance coverage verification.
I do hereby ce i atns ft=da&es of perjury that the utforrnation provided above is true and correct
- - - Ji'til ��� �•oo�
—S-iQ*ta / ------ i ate-
Phone=: 1 Lj I?7 ;do U0-oz�6 —
v-rrrrrn/use only- Im not xvrtte LT2 th r area, to be complrrred by city ur town o�cial
City_or Town: _ -----_ _- --- P--er-mit/License
Issuing Authority(circle one):
1.Board of Health 2.Building Department City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone T
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction��Supervisor: Not Applicable ❑
Name of License Holder: ,�ti) �0� �C�210i� C,,) 45 59,60
License Number
it 1
Address Expiration Date
�f L --Ca2-y
Signature Telephone
CS
9.Registered Home Improvement Contractor: Not Applicable ❑
t-)c` e-S,7, GonLAA,n 14 r c- 15g G e c "I c 3q Ica
Company Name J Registration Number
6 . �,&3 , �- p(09r.-ra52• -7 1 2Fs/OY
Address Expiration Dale
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-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 acting Construction Supervisor your presence on the job site will be required from time to time, dunng 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 F7 Addition ❑ Replacement Windows Alteration(s) Q Roofing
Or Doors LI
Accessory Bldg. ❑ Demolition 0 New Signs [O] Decks Siding [p] Other[p]
Brief Description of Proposed
Work: Or- 5durwC*_, F�a�. C�4�-Z %-3r'40 p
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa 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?
i I
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
A),al'A 2,,C L&✓ as Owner of the subject
property
hereby authorize �t1����M t; � ��►-�
to act on y behA in all matters relative to work authori ed by thfsbuilding permit application.
L;
ature of Owner.! Date
1. , 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 under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
Section 4. ZONING I 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
parking)
#of Parking Spaces
Fill:
(volume&Location) _ _-------- ..m. .... .... °r ..... _... _... ... ..,
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW ® YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 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
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
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
IF YES, describe size, type and location:
E. Will the cnnctn-irtinn nrtivity rli5turh(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.
Department use only
City or Northampton Status of Permit:
Building Department Curb Cut(Driveway Permit
212 Main Street SewerLSepticAvailability
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
This section to be completed by office
1.1 Property Address:
ea '17rwaw$or► � ,�s Map Lot Unit
�....vcc VX'N- a 1 o6 G
� Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Narrl.e int) Currentt Mailing ddress:
NJ 31 S�i6 6
Zn/ Telep one
nature
2.2 Authoriz ent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building G �C' (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
2, 00w Construction from 6
3. Plumbing Building Permit Fee
Z o°V
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) O 4X>-, Check Number D
a` This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
BuildingCo–m--m is-s-i on—dlns pecto�ol-6w f d mgs - ate
J w
File#BP-2008-0667
APPLICANT/CONTACT PERSON R DEAN ACHESON
ADDRESS/PHONE P O BOX 1052 WILLIAMSBURG (413)268-0246
PROPERTY LOCATION 80 DREWSEN DR
MAP 35 PARCEL 106 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: CONVERT 2ND FLR CLOSET INTO BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 83968
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO. ATION PRESENTED:
pproved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Building f icial Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
BP-2008-0667
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)
Category: BUILDING PERMIT
Permit# BP-2008-0667
Project 1r, JS-2008-001020
Est. Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: R DEAN ACHESON 83968
Lot Size(sq. ft.): 9016.92 Owner: ZUCKER ROBERT G&ANDREA HEAPS
Z_onina SR Applicant: R DEAN ACHESON
AT. 80 DREWSEN DR
Applicant Address: Phone: Insurance:
P O BOX 1052 (413) 268-0246
WILLIAMSBURGMA01096 ISSUED ON:113012008 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT 2ND FLR CLOSET INTO BATHROOM
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 1/30/2008 0:00:00 $50.003014
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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80 DREWSEN DR BP-2008-0667
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 35 - 106 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate gory: BUILDING PERMIT
Permit# BP-2008-0667
Project# JS-2008-001020
Est. Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use_Groun: R DEAN ACHESON 83968
Lot Size(sca. ft.): 9016.92 Owner: ZUCKER ROBERT G&ANDREA HEAPS
Zonin.g: SR Applicant: R DEAN ACHESON
AT. 80 DREWSEN DR
P O BOX 1052 413 268-0246
WILLIAMSBURGMA01096 ISSUED ON.1/30/2008 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT 2ND FLR CLOSET INTO BATHROOM
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:
I
6103W Driveway Final:
Final:.-'/6 WFinal: A-
Z ����
�8� Rough Frame:0k 3
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: .�'16+ Smoke: Final: / -Qg.. q�
THIS PERMIT MAY BE REVOKED BY THE CI)W OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc Signature:
FeeType: Date Paid: Amount:
Uuiklin� 1/30/2008 0:00:00 $50.003014
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo