16C-003 (5) The Commonwealth of Massachusetts FOR
1,. Board of Building Regulations and Standards
Massachusetts State Building Code,780 CMR MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
334 SPRING STIR., FLORENCE, MA 01062
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
_� (��_o�Ann LQ 14 Q y u.t( FLORENCE, MA Qi Q62
Name(Print) S City,State,ZIP
334 SPRING STREET 413-237-7326 jblangmuir1189yahoo.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Propos d Work 2: /�t°iLi. 0✓e k `S �t 'h
_ l2 S vs2 �P�jC
-V e—
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
�.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ — ---- ---Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ , fO 0 0.,00 ❑Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 CDcutruction Supervisor License(CSL) 0 Z�
JIt f/ 'e s 't/Z(/[ License Number Expiration Da
Name of CSL Holder
/P�fih�� I /� List CSL Type(see below)
No.and Street Description
&AIL, � Unrest ricted(Buildings u to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,Stag M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
144 P1 I I I Insulation
Telephone mail ad4ess D Demolition
5.2_-Registered Home I ovement Contractor(HIC) 1 C� 9 / 2J `�� �f k —r /HIC Registra(ti Number E)(piratiA Date
HIC Company Name or HIC Registrant Name/117 1� � ( , ' Ctti CCD Ikk4
No.and Street L Email addres
City/Town,State,ZIP Telephone
SECTION 6: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 Issuanc f the building permit.
Signed Affidavit Attached? Yes ..........V No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1
I,as Owner of the subject property,hereby authorize �f/Gl h pia ak omes yls-h UC4(m
to act on in behalf,in all matters relative to work authorized by this building permit app 'cation.
"Zl 3/z,; I K
P r s Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I reby attest under the pains and penalties of perjury that all of the information
C ntained in s a licat. . T d accurate to the best of my knowledge and understanding.
P t ner f I A•thorized Agent ame(Electronic Signature) ate'
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at.www.rnass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed__ ______ Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
City of Northampton
\5 S/
Massachusetts
Ir�Y "S DEPARTMENT OF BUILDING INSPECTIONS ;7 Ma
a
z , fi 212 Main Street • Municipal Buildingv �b
Northampton, MA 01060 sstj1 y�t\�
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 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 any 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
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.
Date
Address of work location
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizationdndividual): qAmtJ
Address:
City/ tate/Zip: a e �' ga 16 23 Phone#: ��✓
Are u an employer? Check the ippropriate box: Type of project(required):
1. I am a employer with__ 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.rmbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. of repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. 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. 1
Insurance Company Name: c �D
Policy#or Self-ins. Lie. #: w C�` 3�� �� � `° �1� Expiration Date: LAO&T I 1 o
Job Site Address: _-23� City/State/Zip:
Attach a copy of the workers' co ensation 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$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $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 DIA for insurance coverage verification.
I do hereby certify under t e pains and enalties of perjury that the information provided ab ve is ue and correct.
Signature: Date:
Phone#: v
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
C 4t
Name of License Holder: ✓t
��I J 01 Uq3 License Number
l��l JTo-JT Oath � c t � _rd t
Address Expir lion n ate
i ature Telephone
9.Re istered Ho me Im rovement Contractor. Not Applicable £
_. _.
Company Name Registration Number
Addr ss3 �-) Ll Expir tion ate
Q 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 buildine 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 as mes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,St to and Local Z ing 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
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [Q Siding [❑] Other[❑]
Brief Description f Proposed p
Work: rek( � shi �S fhS�a��e� v�cQ�✓l� � t,� irk r��s7 Ven
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. lf`New douse and or%add'ition torzezisting 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
V o n aL fi a h �a (� 114 V//^ as Owner of the subject
property f
hereby authorize a w vi a kA I,,
to act on my behalf, in all matters relative to work a horized by this building permit application.
Signature of Owner Date
I--
I as Owner/Authorized
ereby declare that the sta'rents 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.
�r _
J__1 G1 INLL
Print Name
Signature I O ner/Age Date
� ^
'
Section 4. ZONING AtI.Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
11iis column to be filled in by
Building Department
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has u5peciai Permit/Variance/Finding ever been issued for/on the site?
x��
«~� �~� �~�
NO v�/ DON7KNO\� Y[3 «��
IF YES, date issued:[ �
IF YES: Was the permit recorded at the Registry ofDeeds?
NO K ) D '
�� _
IF YES: enter Book Page[ and/or Document#
B. Does the site contain a brook, body cf water orwetiands7 NO 0 DON7 KNOW 0 YES 0
IF YES, has permit been orneed to be obtained from the Conservation Commission?
Needs tobeobtained x~� Dbtained �~\ Date
�~� �_� ' .
C. Do any signs exist on the property? YES 0 NO 0
iF YES, describe size,typeand tocation:
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: i |
E. VWU the construction activity disturb(clearing, grading,excavation,or filling)over 1 acre oris it part ufa common plan
, that will disturb over 1acre? YES NO ��� �
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
'1
t:
. City of Northampton $�tatuSiQ _r,
11 l —^Ir - alit}e w: i.0
r — - . Building Department Ur$Cut/Di ivewar
rx£i�r 131 t
!i 212 Main Street Seyver/SeptlGAtaira�illrty °� yy ' I•I `� ` "� f
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2 Room 100 ., er/V eTEAvaflabllity i n
I J, �,i I £ire Iw 1 ..
i Northampton, MA 01060 TwalSefs�pf5#ru�tctr�l?tans£ as, iy a i yyI n j
r - j,�i) Y S!P G` a Ilr �4L h .' i ♦• M 1
�� -- phone 413-587-1240 Fax 413-587-1272 PIo/3ite Plans_
g
1 r ... _ ♦ � �Le vy.1'f G j £ 3 1 Ti �Y� �� �i Il r.r,i F� i
!_. °� .:. '„< ; ':Dther2S:pecifyr.k,t�I ��h.?21 � �,*x�, �.A.l=. d �' i��,i• y �`u.
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
Nh
s�r� Ma Lot Urnt
Z ,
C>✓ Zone Overlay D►str►ct
I
,
Elm St Distr!ct CB Dlstrlct
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT'
2..11 Owner of Recor d:
\Jbbt�i la /14,14 G144U
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: C�,,7,✓
Name(Print) Current Mailing Address:
Si n ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Feb
2. Electrical (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) 0 . 00 Check Number b clL
This Section For Official'Use Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissionedlnspector'of Buildings Date
334 SPRING ST BP-2014-0980
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16C-003 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-2014-0980
Proiect# JS-2014-001702
Est. Cost: $17600.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES FLANNERY 103061
Lot Size(sq. ft.): 43864.92 Owner: LANGMUIR JONATHAN
Zoning: URA(100)/WSP(100)/ Applicant: JAMES FLANNERY
AT. 334 SPRING ST
Applicant Address: Phone: Insurance:
56 CHESTNUT PLAIN RD (508) 294-4052
WHATELYMA01093 ISSUED ON:312612014 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & INSTALL METAL 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 3/26/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner