36-278 (2) SEPF RTAfENT OF BUILDL\G LNJS.-.S=ONS 5v=_
212 Main Strut a Municipal Buildmiz C.L'VSFECTCR P
Northampton, NFA 01060
Hv13M ONVNER LXEML IPTI ON ACI NnWL FDGENIENT
The State of Massachusetts allows the homeowner the right under 7SOCINa7).4to
act as ris�herconstruction sup.._ :;or. The state defines "Homeowner" as, "who owns a parcel on which he/she resides or intends to be, a one or two fa&velling, attached or detached structures accessory to such use and/or farm
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 thew`own const uc:on 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 worm at various stages, which include foundation/footines (before back-fill).
sonotube holes (before pour). a rough building inspection(before work is
can-ceded), insulation inspection (if required) and_afinal_buildin-einsDection. 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-inspect-ed.
Ythe 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
L understand the above_
(Home owner/resident's signature requesting exemption)
I will call to schedule aII required buildin,inspections necessary-for the building permit
issued to me. y
Date
Address of work
location
t �
The Commonwealth of Massachusetts
—�— Department of In dustrial Accidents
Office of In vestigations
f J 60 Washington Streer
Boston,M-4 01111
www.massgov/dia
Workers"Compensation Insurance Affida-vit: Builders/Contractors/Electricians/Plumbers
ADplicant Information Please Print Leigiblti
yaMe(Business/Organiation/Iadividual): �✓ ��,�
Address:_ 1 UYKPQ LJ k1A_1
City/State/Zip: G(f R Pi\As b-lf Phone,:
Are you an employer?Cheek the appropriate box: Type of project(required):
I- I am a employer with 4. 'N I am a general contractor and I
emplovees(full and/or part-time).
have hired the sub-contractors 6. ❑New construction
2 l listed on*fie attached sheet 7. Remodeling I
I _.�I am a sole proprietor or partner-
ship and Have no employees These sub-contractors have S. Demolidon
working for me in any capacity. employees and have workers' 9 �Building addition
'No worke s'co=.i0suiunce comp.insurance
requi;ed-j v 3. LO vv e are a corporation and its 10- Elect cal repairs or additions
3.0 I am a homeo-wMer doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. 'co right of exemption per lvfGL
�o workers tap- 12.[]Roof repairs
insuaance required.]t c. 152, §1(4),and we have no
ezaployees. [No workers' 13.0 Other
coma.insurance required.]
---� n, applicant =ecxs ooxr l asst aso=out me secaon oe:ow snowing ea wor'�s'compensation.poucy information.
Homeowners who submit this affidavit indicating they are doinz all work and then hire outside contrac•.ors taus:submit a new a;adavit indicatEng such.
'Contractors that check this box mustattacaed an additional sheet showinsr the name of the sub-conttac-ors and state when er or not those entities have
cmnioye-s. If the sub-contractors have crmicv=,they=st provide their wor'sc s'cam.policy number.
lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
znformalion.
Insurance Co=any Name:
Policy T or Self ins. Lic. Expiration Date:
Job Sire Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(snowing the policy number and expiration date).
Failure to secure coverage,as required under Section 25A of MGT.c- 152 can lead to the imposition of criminal penalties of a
fine up to S I-500-00 and/or one-year imnrisonnment, as well as civil penalties in the form of-a STOP WORK ORDER and a f-e
of up to 3250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investisations of the DLA.for insurance coverage verification.
I do hereby cernff u the ai anakjes of perjury thar the information provided above is true and correct
D ate: 0 U
Phone#-
�U
vF X=use onLv. too not wrzte in this area, to be complered by cizv or town official
City or Town; _------P-ermitlLicense
lssuin;Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 1.Electrical Inspector 5.Plumbing Inspector
1 6. Other
Contact Person: phone
F CTION 8-CONSTRUCTION SERVICES
Licensed Construction Suoe/r�vi�sor:� Not Applicable ❑
Name of License Holder:_
—T License Number
tal2z,—
l09
Address It Expiration Date
to
Signature Telephone
9. Registered Home Improvement Contractor` Not Applicable ❑
- �(�
Company Name Registratio Number
Address
�/ Expiration Date
G U!l f)z .//s 1 tl P �l o� 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...... ❑
I1. Home Omer 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.CTNtR 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 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [M Siding [01 Other[p]
Brief Description of Proposed I
Work:_ no E3 yt,4 X r7uo tzaer IR :7-ww F- wm-x y S
Alteration of existing bedroom Yes A' No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes >-e No
Plans Attached Roll -Sheet
6a. if New house and or addition to existing housing> compiete 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 ,�,, `
hereby authorize �i4//a c hpae C f'�s
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I; �[.�/L �/�s y E:�pO p w� c .(7� flW S>�Nf I�'e%SGt/J✓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
to 0
Signatu e of Owner/ gin Datef
Section 4. ZONING Alt 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 °lo
Open Space Footage
(Lot area minus bldg&paved _ --
oarkine)
#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 0
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
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 Qr
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
o
Building Department Curb CuVDriveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
4North�mpton, MA 01060 Two Sets of''Structurat 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
1.1 Property Address:
This section to be completed by office
.51 (Alo v IDS 1Z �}- Map Lot Unit
NQ��w�R rJ Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY'OWNERS HIPfAUTHORIZED AGENT
2.1 Owner of Record:
?6-'l-^ft JUUO ZuCr S t W Odt1S 't2� �[CCt,t1lC'F /�A- OI Obz
�zage•(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: CUl7/11NG-
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit apeficant
1. Building Of Coo (a)Building Permit Fee
2. Electrical 5 0 U "' (b)Estimated Total Cost of
( Construction from (6
3. Plumbing 3 t7 "� Building Permit Fee
4. Mechanical(HVAC) j ( 0o o
5. Fire Protection
6. Total= (1 +2+3+4+5) QV 0 Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building,Commissioner/inspector of"Buildings - Date
J
File#BP-2008-0634
APPLICANT/CONTACT PERSON MARC HOECHSTETTER
ADDRESS/PHONE 45 LUTHER SHAW RD CUMMINGTON (413)634-5480
PROPERTY LOCATION 51 WOODS RD
MAP 36 PARCEL 278 001 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: CONSTRUCT MUDROOM WITHIN EXISTING GARAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 61816
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved 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
Si-nature of ding Of 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.
J
BP-2008-0634
GIS#: COMMONWEALTH OF MASSACHUSETTS
i' 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-2008-0634
Project# JS-2008-000964
Est. Cost: $48000.00
Fee: $240.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
i"se Grow : MARC HOECHSTETTER 61816
Lot Size(sq. ft.): 49745.52 Owner: HAAS PETER M&JULIE ZUCKMAN
zoning: SR Applicant: MARC HOECHSTETTER
AT: 51 WOODS RD
Applicant Address: Phone: Insurance:
45 LUTHER SHAW RD (413) 634-5480
CUMMINGTONMA01026 ISSUED ON:112412008 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT MUDROOM WITHIN EXISTING
GARAGE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
tinderground: 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 1/24/2008 0:00:00 $240.002939
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
�T
�� s� �� �'y'��.�1,.��y ... ('��—f°LJ�' ,'� ,e�cU'�j`iL,�� ���G7 f.r�:l��l�f�/�.,�, � �i.�,
5 t WOODS RD BP-2008-0634
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-278 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL C.142A)
Categ BUILDING- PERMIT
Permit 4 BP-2008-0634
Project# JS-2008-000564
Est. Cost: $48000.00
Fee: $240.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARC HOECHSTETTER 61816
Lot Size(s . et.l: 49745.52 Owner: HAAS PETER M&JULIE ZUCKMAN
Zonis-: <'R Applicant: MARC HOECHSTETTER
AT. 51 WOODS RD
Ilrt.ILI I sS:
Phone: Insm-ance:
45 LUTHER SHAW RD (413) 634-5480
CUMMINGTONMA01026 I ;SUED ON:112412008 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT MUDROOM WITHIN EXISTING
GARAGE
t�.4_R_D `_)'O IT IS VISIBLE FROM THE STREET
Inspe,.tor of Inspector of Wiring D.P.W. Building Inspector
I!nderground: Service: Meter:
Footings:
Rough:��� p House# Foundation:
l^� � Driveway Final:
Final:
Rough Frame:Frame: O K C - 0
�-L ,
Gas: Fire Department Fireplace/Chimney:
_ r
Rour�h; Oil Insulation:
n
1 final: Smoke: Final:Qtc
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
✓' sn i'' t°' e„ 1- mot,,*•
Ceftificate of OccupanC Signature:
FeeTyt;e: Date Paid: Amount:
Buildin, 1/24/2008 0:00:00 $240.002939
212 Main Street.Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo