35-108jo 11:211-
12 iN/I: zi:: .SLR... Nf I-IIECZLl E
C 0-1 C j A
CC I
la 0 yII
E ;jib 4ER '7XIIVTFTIO'-,: ACE."ONYLIEDGENIENT
I The State o-f-Massachusetts allows the homeovvnerthie rig ht under 780C-Na 108.3.4 to
a(" ConstLC1:0r Th- state defines "Honeow ner" a, erson(s)
.
who ov,-i:-- a parcel on which h e! shl. e resides or intends to be, a one e or
dwe-F.,.ng, a:- .ached or detached stnica.,res acces---or-,,, to such use andlor farm st-uCtL-'es.
I Person 'V�ho Constructs more than: or considered
home owner."
Le home jr, a period shall not be
-C. � Qerson(s) 'Wh. 0 seek to
The buE d d- iz�paitmentt for He C 0 Norha" ants 2n r ME-
us�- the home O-Tvner exomptor" to aC: e�; —1 —7;<�� to
Lieu U vv 11 'ZzStI-L==- s"Ip-
that by doing so you become responsible for compliance with state building codes
and reg-ala&US'The inspectlot -. process requLres that the building departm, ent be called
to i=.pect wor-� at various stages, which include foundation/footings ('before backTIA'A
sonotabe holes (before oour). a rough building ingrection (before work is
c".cr.-0ed)-. in&-alation ir�si;Lectian (if reguired-) =d-g fing! hu dinginsrer-tion- The
bu.ildin!z depa=eni requires these inz-aections before the work is concealed, failure to
secure these . fg-suections can result in failure to obtain 'a ce.-tificate of occui)ancv
untilthe-w-arik. tan-bej=D-e--te--L-
L-7the hob eo,;;yer hires other t"rades to per :Form work (electrical plumbing & gas) the
ho eow�er �bleto,7-T-es-L,_et that traces h,: - -, e their proper
% sure ha _e tra(f red P
-�vui be r�-.SPCLSI 11. se'7 ir
Fe =.nits in c,-zjuz='cn to the building peen- -it issued, and that they get their required
inspections- FaHlure c-FiLe trades to se--jre the pe,-=7s and L,=e--tiozs as
reauu ed can DEHAY the PrcJect unrl"T sack time as the proper pewits and =pections are
made
X
-anderstand the above-
(Home owner /resident's signat-ure requesting exemption)
I will call to schedule all rec-uire'4 buifd.; 2 Fe,-,=t
mg inspections necessary for the building
Issued to me.
Date
Address- F
I CEDE G-
L
• ._ Department of f Inriilstriad Accidents
- Office of In vesti; ations
600 Washin,;ton Street
Boston, I _VA 02111
WWW.rnass. j ov1dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
AD Tics. t Information Please Print Ledbly
Name (Business; Organization /Individual):
A ,�,-1. -���
c-_uui ess
City/ State! Zlp:
Phone n:
Are you an employer ? Check the appropriate box:
❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and /or part- time).
2. ❑ I am a sole proprietor or partner -
ship and have no employees
vvodcin� for me in any capacity.
[-Vo workers' comp. insurance
equired.]
�.'' I aril a hor_Zeowner doinv all work
myself. [ATo workers' comp.
insurance required.]
have hired the sub - contractors
listed on the attached sheet.
These sub- contractors have
employees and have workers'
comp. insurance .T
5. ❑ We are a corporation and its
officers have exercised their
rig ht of exemption per MGL
c. 152, s 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
S. VDemolition
9. ❑ Building addition
10.7 Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.7 Roof repairs
13.❑ Other
'Any applicant that checks box —,I must also fill out the section below showing their worcers' compensation policy information.
no meowners who submit this affidavit mdicatina they are doing all work and then hire ouisidecontractors must submit a new affidavit indicating such.
Cuntractors tl;at check this box must attached an additional sheet showing the name of the sub- contractors and state whether or not those entities have
en�pioyees. 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 Naive:
Policy or Self -ins. Lic. #:
Job Site Address:
Expiration Date:
Ciryy /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 NIGL c. 155 2 can lead to the imposition of criminal penalties of a
f!ne up to S1,500.00 and /or one -year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S230.00 a day against the violator. Be advised that a copy of this statement maybe fonvarded to the Office of
investigations of the DIA for insurance coverage verification.
1 do hereby cer ti fy trnde; tlie- pains -crntl penalties- tr- perjtHy -that the information provided above is true and correct
— - /
Si�iature�..�w. Date_: (�
City or Town:
or town o
PermitiLicense r#
IssuL,12 Authority (circle one):
_. Bcard of Health _. Building Departinent 3. Cityi To.vn Cler% -1. Electrical Inspector P ;umbinl Inspector
b. other
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
Name of License Holder
Not Applicable ❑
License Number
Address
Expiration Date
Signature Telephone
9. Registered Home Improvement "GOrttractor:
Nut Applicable ❑
Company Name
Registration Number
Address
Telephone
Expiration Date
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. CNIR 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, 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 0
V
SECTION 5- DESCRIPTION OF PROPOSED WORK {check all applicable)
New House ❑
Addition ❑
Replacement Windows Alteration(s) ff-Roofing
Or Doors D
Accessory Bldg. ❑
Demolition
New Signs [❑] Decks [M Siding [❑] Other [C3]
Brief Descr�ip E f of Proposed j ` �GAc e- P ,A -t,A C �f �kA' rV
Work: I�;t7L1iC'e r'�_�'liS1�2CNT �:4( =j-} / � �' t nwa
Alteration of existing bedroom Yes _1Z No Adding new bedroom Yes �� No
Attached Narrative Renovating unfinished basement Yes N
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
I, 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
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 the pains and penalties of perjury.
under
(`s'eP -AL b--1Nr PC..e --fQV
Print ame �
XGI �,J
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
Setbacks Front
Side
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
# of Parking S
r
L: R:.
I
Fill:
(volume & Location) _....- ._ .... _,. ._-. -. ___..... _._.__ ....
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 6�' YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 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
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 construction activity disturb (clearing, grading, a cavation, 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.
w ti
•
`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:
Map Lot Unit
Zone Overlay District
Elm St District CS District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
x
Name (Print) / ` Current Mailing Address:
�.
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 ermit applicant
1. Building�o
`� ` C�
(a) Building Permit Fee
2. Electrical
(b) Estimated Total Cost of
O r �' • G
Construction from (6 )
3. Plumbing
Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2+3+4+5)
�?L�r �� f.
Check Number
This Section For Official Use Only
Date
Building Permit Number:
Issued:
Signature:
- - --
Building Commissionon er /Inspector ofBuTdmgs
- ate
File # BP- 2010 -0014
APPLICANT /CONTACT PERSON TEMPLETON GERALDINE
ADDRESS /PHONE 26 CAHILLANE TERR FLORENCE (413) 586 -2043 Q
PROPERTY LOCATION 26 CAHILLANE TERR
MAP 35 PARCEL 108 001 ZONE SR(100) / /WSP II
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: REPLACE FRONT PORCH POSTS & REPLACE PATIO OVERHANG
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FQLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER: §
Intermediate Project: Site Plan AND /OR
Major Project: Site Plan AND /OR
ZONING BOARD PERMIT REQUIRED UNDER:
Finding Special Permit
Special Permit With Site Plan
Special Permit With Site Plan
Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW
Septic Approval Board of Health
Water Availability Sewer Availability
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
11122-
Signature of Building Official
Zvo�
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.
Category:
BP-2010-0014
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Permit # BP- 2010 -0014
Project # JS- 2010- 000019
Est. Cost: $5000.00
Fee: $55.00
Const. Class:
Use Group:
BUILDING PERMIT
PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
Homeowner as Contractor
Lot Size(sq. ft.): 9931.68 Owner: TEMPLETON GERALDINE
Zoning: SR(100) / /WSP II Applicant: TEMPLETON GERALDINE
AT. 26 CAHILLANE TERR
Applicant Address: Phone: Insurance:
26 CAHILLANE TERR (413) 586 -2043 (�
FLORENCEMA01062 ISSUED ON. 71712009 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE FRONT PORCH POSTS & REPLACE
PATIO OVERHANG
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W.
Underground: Service: Meter:
Rough: Rough: House #
Driveway Final:
Final: Final:
Gas: Fire Department
Rough: Oil:
Final: Smoke:
Building Inspector
Footings:
Foundation:
Rough Frame:
Fireplace /Chimney:
Insulation:
Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeTvpe: Date Paid: Amount:
Building 7/7/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo