25C-045 J
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o DEPART MEIrT OF DUILIDD\'G INSPECTIOI.'S -
212 ?lain Strcct ' 'INfunicipal Budding
NorLhampton, Mass. 01060
W O EUCE z'S C O NC EN S A TI O N M S V J. A-N CF- A 1'FU),i vi-j,
v"Ith a plZncipal place of bu.sinessfresidence at: —
- --
(ph one:=)_:
(sar_..ticz ty�statcla n)
do hereby certify, under die pzin5 and penalties of perJury, h:t
( ) I am an employer providing the foil owine'%vorke>'s cotnoensadop cove mgc for my
emplovees worUng on this job:
Q1Lnu-m Corer .) (Policy Nt>_ r) --- :pirtiorr DzL)
( ) I am a sole propretor, general contractor or homeowcer (ci cie one) and have hired
the coaractgrs listed below who have the folloVyM' S worker's comoen_sadon pc!icies:
+QID: O. CO^!^Ci0"1 (Instranc;c Cotmoan}'!f'oucr il11ml, ) �_`-.)al:op Oatc)
i
(Name of Concaaor) (lnsurzne amoaawpol c-' Numn--r) �aDirdon Date)
(Name of Coaa-acd:) (Lase a.nc: Compare}•fraud• Nwnbj) (Expirdoo Dam)
(Name of Contractor) (1_nSUrmc-- Comc--ay/Policy Numbzr) (E.xpir<doa DaLc).
(atxs,ch..li.COC3.l r'�ca.irncoci.O•to cx?vd`iaformi;oa pctain.:as to.11
X011'am a sole proprietor and bave no one worm
g for me.
( } I am.a home owner performing all the %York myself.
NOTE:plc be conic ti- .t ]c 6cmcwvcr�_bo !
a=P oY Pcsons to do�3 cs.:c.ix c rcpaa wor-k oa. of
aoe mete th=at w tai's in etch the bocnoo-.cr reads oc oc tb,
II'o,� �the-ro rz wt godly oee3id-cad to be
"'Plor'unr--the —P= -x Act(GUI 32` 1(5)} =pplia000 try a bomco as fl=c bey_or pamit r=Y-idmec the
Icgsl rtzau of ea es�loyx wader tho Waricda Coaxpomalip¢A�
I uod-mt d tha a oopy of thi. c,=_=m..y ba(ora.ur•ded to tha D,9_,n o f Io&arricl Accdeatr'Off oo of 4aur.00e ror th.
wv-.asc-irc:tioa aid th=t U- tac to soaucbov,asc tmdc:.ociioa 23A of MOL 152 can Icd to the imposidon cdaimic-U pc ,W-
00-i:mg of a lice of trp to S I X00.00-&Or 6=pr6oacoc=of up to coc ym=end a,.-1 p=j r� a in 6c form o(a Stop Work Ord-. and a
fl=arSloo.00 I d--y try me _
~ For dam,r u,c only --•---
permit NUML--
1`�ap:—_ Lot
St rc f i c ttcc e J ¢.
¢SHAa1P�.
Y �
C111 ity of Xort4alllpton
$" ki �'rlassacf�icsetts -
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building
Nortli,unpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to
act a. his/her construction sup,::,• so.r. T he state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two famiry__--
dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a
i home ow.:er" -
The building department for the City of Northampton wants any person(s) who seek to
use the home owner exemption, to act as their own construction supervisor, to be aware
that by doing so you become responsible for compliance with state building codes
and regulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footines (before backfill).
sonotube holes (before pour) a rough building inspection (before work is
concealed) insulation inspection(if required) and a final building inspection.;The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
T�rho i,.,..,o...,.,,o t.+rne nrhnr tr$deS t^ narfnrm ;1;vrl! �P1Pl`tri(val nliimhinv Rr aacl the
11 111V 11V111�V VV 1/Vr 1111 VJ V1.11V1 rya ava aaa - �v-v.vr , r------�---a a—�i .
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
r
SECTION 8-CONSTRUCTION SERVICES a
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: i G-5 0'7,1 a 3 �
License Number
Q�,- x �';s"� y -h►�y� 1 � vim 4 --Ie&
Address Expiration Date
.5r 37 f
Signature Telephone
ftfti6 d-K& -1&6ibveitient Contracfni y g ,z Not Applicable ❑
Dqvij i94S'31
Company Name Registration um e-r— - --
Address (( Expiration Date
✓"'Xy-"46ic Telephone J�
SECTION 10--WORKERS'COMPENSATION INSURANCE-AFFIDAVIT-(M.G;L.c.1.52,§,'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...... ❑
The current exemption for"homeowners"was extended to include O.:per=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,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
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SECTION 5DESCRIPTION OF PROPOSED WORK(check'all applicable)
New House [] Addition ❑:. Replacement Windows Alteration(s) ❑ Roofing
Or Doors Cl
Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [[] Siding[o] Other[a]
Brief Description of Proposed
Work: t'"elNJaW 9_10$j 2 4r+
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a ��-'[`1evu�iause anc�-or��additan�.i�c�e'xlsf�ic �tacisncr.compiefe�[�e��orCCai� ic:
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 BWL DING,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 perjury. '
Print Name
Signature of Owner/Agent Date
Section 4. ZONING All Informatio'n 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
Rear
Building Height
Bldg. Square Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume-&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
No 0 DON'T KNOW 0 YES 0 �
IF YES, date issued::
IF YES: Was the permit recorded ut the Registry o[Deeds?
NO ^ ` �GmT ���Vv Yre
��
IF YES: enter Book Page and/or Document# !
�� ��
B. Does the site contain a brook, body of water orxvet|ands? NO �_��/ DON7KNOVV �_/ YES �~�
IF YES, has u permit been orneed to be obtained from the Conservation Commission?
Needs tobeobtained x���~� Obtained �-�~/\ Date'
C. Do any signs exist on the propwrt �� ��y? YES �~� NO v��
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, typeand location:
E. Will the construction activity disturb grading,excavation,or filling)over 1 acre nrisdpart ofocommon plan
thawi|\dimurbover1aore? YES K~_^) NO K }
� `~,
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r
City of Northampton Statu. of l?ercnl r
Building Department Cu Cr�tlDewa es �
212 Main Street Sewers
x
Room 100 ViW1e[I1 earl 6 ify r "
Northampton, MA 01060 FTnia etso Strr�cf ra Ph ss `� "
phone 413-587-1240 Fax 413-587-1272 PfottS M �
r _
g7 ZN-
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLI _ A ONE OR TWO FAMILY L ING
L JAI - 6 2005 !-
SECTION 1 -SITE INFORMATION
T isle Meted b ice
1.1 Property Address:
/.
/ �D� o►�� hoc
Overlay Disfrict=
EIm St,Distriict CB DIs#rict -
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: (
Q `?-Go ///r(rye C A J z-c 14
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized en :
V / A
il%� S>L" __� •�7 `� C�"�i'I tfJ� roe G�. �?
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Y Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building / O Building Permit Fee � —
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) Gheck Number
This Sectiorr For Official Use Only
Date
Building;Permit Number. Issued:
Od-
Signature: r CY, L o0,5
Building Commissioner/inspector of Buildings- Date
17 WOODBINE AVE BP-2005-0708
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-045 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-2005-0708
Project# JS-2005-0971
Est. Cost: $15200.00
Fee: $75.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin DAVID DAVIDSON 072233
Lot Size(sg.ft.): 15550.92 Owner: CHURCH DWIGHT S JR&ROSEMARY
Zoning:URB Applicant: DAVID DAVIDSON
AT. 17 WOODBINE AVE
Applicant Address: Phone: Insurance:
P 0 BOX 854 (413) 569-9973
SOUTHWICKMA01077 ISSUED ON.1 17105 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL 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• Receipt No: Date Paid: Check No: Amount:
Building 1/7/05 0:00:00 3034 $75.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
14
BP-2005-0708
17 WOODBINE AVE
COMMONWEALTH OF MASSACHUSETTS
GIs#:
CITY OF NORTHAMPTON
Map:Block: 25C-045 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Lot: lo
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Category:
Permit# BP-2005-0708
Project# JS-2005-0971
Est.Cost: $15200.00
Fee: $75.00 PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
Const.Class:
DAVID DAVIDSON 072233
Use Group:
Lot Size(sg ft.): 15550.92 Owner: CHURCH DWIGHT S JR&ROSEMARY
Zoning:URB Applicant• DAVID DAVIDSON
AT: 17 WOAVE
ODBINE AV
Phone: Insurance:
Applicant Address:
P O BOX 854 (413) 569-9973
SOUTHWICKMA01077 ISSUED 0N:1/7/05 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL BATHROOM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET Building Inspector
Inspector of Plumbing Inspector of Wiring D.P.W.
Underground: Service: Meter:
Footings:
eFoundation:
Rou h: / �j9 House#
Rough:110�a� Q� g �!7lospa•"'�' Driveway Final:
�� .�513 � g 1�' l
Final: Final: �% 5 C�— Rough Frame:D '— o_
Gas:
Fire Department Fireplace/Chimney:
Rough:
Oil: Insulation:
Final: Smoke:
Final:
THIS PERMIT MAY BE REVOKED BY THE ITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS
Certificate of Occu an Si nature:
Feel e:
Receipt No: Date Paid: Check No: Amount:
Building
1/7/05 0:00:00 3034 $75.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo