25A-050 (5) ti
To: Building Department City of Northampton
From: Mark W. Dion
22 Crosby St.
Northampton, MA 01060
Date: August 9`", 2004
Re: Construction Supervisor
I will be the construction supervisor(CMR 780, sixth edition Section 108.3.5.1)
for the work listed below on my property.
Plumbing repairs c ��
• Worn plumbing in the kitchen and bathroom will be replaced.
• Kitchen plumbing will be moved to the street wall for the kitchen sink
• Piping for the washing machine will be moved into the bathroom
• old plumbing for the washer in the kitchen will be removed
Wall repair
• Replace damaged dry wall
• remove closet in living room
• change position of door on the inside of living room and bed room No
• lay new tile throughout house ✓ (,���(S
1 Mark W. Dion will be responsible for all work done under the permit. I will be
on site most of the time if not all of the time. I realize that I am liable for anyone
working under me for this work.
Al
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m DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060 ,
y
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction sups.,i sor. 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 ch time as the proper permits and inspections are
made -1,Z-,I, understand the above.
( e ner rest t s na a requesting exemption)
I will call t6 schedule all required building inspections necessary for the building permit
issued to me.
Date Z'
Address of work
location
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m DE?1RTI,1E-?.'T Of' LUILDP? G INSPECTIONS
212 Mimi Street ' RI'unimpttl Buil(ling j.
Northampton, Mass. 01060 '
WORKER'S COMI T'ENSATTON I SURANCE A 4 t AVIT
�vlda a principal place of busiress/residencc
do hCrLoy f
Cmu ', Lnacr '01C' p !i1S ;iid pCi1 IiICS OI pe.r�ll11' t.Ili!t: -
I ::_m an employer- providing the follov"Im: v.orr.Cr`s compensauon cover :fie or Iny
en]ployees Morld'1Ilg on this job:
(1=,L nC Compam') (PC c;NiI--rebel) ---- (ExTirnen Dale)
�I am a sole proprietor, general c-� ]mac c; r .
t_o.�ieo�.�ver ` -,Cie Oct)one i and ave lured
ll^ OI]%IaCiOrS lISteC beiov . io i1� ih'.' iOl $ COi Den uOr1 ii^v!1C'.cS:
(Z`amc of Contactor) (I c. - LoIP. `: (Ex- .c.. ( -
n nc� ;-,. otic{ Ntymbcl) ;c- Dat„1
(Name of Contacto:) -- (71ts�rnc° Con _rv(Pe!ie; Nlumbcr) (E r Iin Date)
0"?ame of Contractor} (lI]S '1I1CC (_O y ;2�.i/Iyo!,C: NIJII]b r) tij,'r i]o )%atc))
- (Name of Contactor) —- (IDS-ura.tict- ComT::=Y/Policy NumbLr) (T: :ni-::in- Date)
:n:o-:J�.;c:-_�xra::c.:I-=._.::r:;• r.il o-<._:o:-';::•)
I
mm it jo1C pro plICL0i 2:i1Q h ve 110 OI1C -J J1 Yol iP_G.
I ?111 a home C;�V?1C.` iiCi:O"f?11I ?Il t*,-,,
NO"ITi:plc u t�atir� c Ls;.tit:ilc tx<r�o«�r a a',.o c pl.y, n ct . .c_,sancc z:::_n .m cr:r;;air«,:i: d«cl!ir:,c.
not unce th--13[lrr•oo unit,in wL•dt Lhe c-oc;' ^i a x,r cr_r1 Lhccto c c ON c
catployc3 urr cs t}v:tvcrlcfec ccrx-_:a:i^n c!(GL! 2.:-.1(5);,r.,:1:ca ic:;by a F.otarot ncr for a l^ c ct p:rai: tir tc
legal rtatuc of an c=xploy'ec under tarn Wo kve.Co,2,�m_^ bon!,,L
I uz-s=tand th._-cor y of this date•.-al r_uy bo fcn--ie:i to tl»fYpwtarn:of Ir>&Li-ri--J Ar6l' ty C%Il c of for tlx
oovax&-vairictioo and that f-Aurc to to :coy-ram„ut 3: cC,ioc 25A of MG1,152 can Icad to the in,p3sitim o;c ^.1 pasltcu
Comixting of a fur_of up to S 1.S .00 an1'or of'!P trr cr,.)-a:r:-.'I civil pcnaltiu in d o f,-,nn c•f,+
Lr> OfS10O.W e day i :umu tn..
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§26C(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 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 Zomn aws and State Massachusetts General Laws Annotated.
Homeowner Signature /��Y
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) J�q Roofing ❑
Or Doors ;R�
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[�]
Brief Description of Proposed 1 _ Q
Work: csat= �fQ1t.�1tnS^ n� �cTr /1oT c.�n�u1G[;7 (�aw`[ (1( tiyo�\�UL(li}f r': r
G6.W"S.- 12toat CAGY'a
Alteration of existing bedroom Yes No Adding new bedroom Yes _ No
Attached Narrative � Renovating unfinished basement Yes 14No
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
I, ,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 p rjury.
Print Name
�"""1&;�� - S
Sign u wner/Age 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 .6 5 S
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
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW ® YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW ® YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW ® YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ® , Date Issued:
C. Do any signs exist on the property? YES ® NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO
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 ® NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
r ment Curb Cut/Driveway Permit
l5 2 a eet Sewer/Septic Availability
Roo 1 Water/Well Availability
(� W pt 01060 Two Sets of Structural Plans
!;
j ' b�te�4 5 12 413-587-1272 Plot/Site Plans
Other Specify
A LICAA i yt n"biLTER EPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
4 >
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot V Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
2
trc s t
Name(Print) Current Mailing Address:
Telephone
Signatur .
2.2 Authoriz d 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 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing n �., Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) S iX Check Number
This Section For Official Use Only
Building Permit Number: �/���� Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2005-0182
APPLICANT/CONTACT PERSON DION MARK
ADDRESS/PHONE 22 CROSBY ST NORTHAMPTON (413)586-2237 Q
PROPERTY LOCATION 22 CROSBY ST
MAP 25A PARCEL 050 001 ZONE URB
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 DAMAGED DRY WALL REM CLOSET&CHANGE DOORWAY
New Construction
Non Structural interior renovations
Addition to Existin¢
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
TH�Aot)rov
O LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN ATION PRESENTED:
ed A dditional 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 Commissio
Signature of Building Official 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.
22 C€LOSBY ST BP-2005-0182
GIS#: COMMONWEALTH OF MASSACHUSETTS
25A_054 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2005-0182
Project# JS-2005-0204
Est. Cost: $4000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 19384.20 Owner: DION MARK
zoning:URB Applicant: DION MARK
AT: 22 CROSBY ST
Applicant Address: Phone: Insurance:
22 CROSBY ST (413) 586-2237 0
NORTHAMPTONMA01060 ISSUED ON.8116104 0.00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE DAMAGED DRY WALL, REM CLOSET &
CHANGE DOORWAY
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 OccuQancy Sienature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 8/16/04 0:00:00 1513 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo