25C-070 9
9 R•, i.
�� ! f
w,
t
-
s
a. »
i
, 5y
win
oil
Non a
r.
to
�,✓
its
sue,y t
AS
is t
y
r
� r
t� 4�Ar✓`ri _
Of kTc1ri[jaillp toil
A E 51x3%achnccIIz' - _—
w DEPARTMENT OP DUILDO\'G INSPECTIONS
212 Main Street * Municipal Building
Northampton, Mass. 01060
WORICER'S COMPENSATION MSUSNCF .FNMA FIT
v,rlth a pi-Mcipal place of businessJres1dencc at:
-
(M,=t/ci ty/stale/zi P)
do hereby certify, under the palms and penalties of pcgury, -h:l
( ) I am an employer providing the followint worker's comnens-nDon coverage for illy
eluployccs worl.Jing on tills job:
(trLSUS z= Cocra-n -) (Polio: Number) ---- (r:-piration Dac)
( ) I am a sole proprietor, general contractor or homeowner (ci:cie oee) and hive hired
the coauactors listed below who hive the following workers policies:
(iiam-_ Oi Con'mci0r) (ki-sumnc Cotnoan)'i?obc; Namh) (1=? )IiJIiQ Os IC)
(Name of COpITaClor) -- (lnsurane amoauv/Pol cv Nu a3i?:0 T��it tion Date)
(Name of Coan-acior) (IJuu-anc:. Compaoyfpouicy Numbs) (Expiraaou Date)
(Name of Connmor) (Lasuranc:�t Company/Pobcy Numbs) Txpu-,,doa Darr)
(enich Uj-�tiOcal cScct ifnc ,,-to mcJu��nfocmi-'loo rxruiains Lo.L co=-_c.o-�)
( ) I am a sole proprietor and have no one worLzing for me
( I am.a home owner performing all the work myself.
Z' `NOTE:pl= be a ut djc u{Jc wbo cxaploy pelota to 'w mx cjc ••••;c,,:-,r_jcc c-rcpau oric on c dL^z of
nne tmco th n tLr--t-aro rn t in6 the bocnoowncr[cider oc ao Lb,g oua tt z partcv r1 tJrr o LT ocK�c cc!!y oz.3&--rcd Lobe
-aV[Oy-undo the t.a�oC3`y'c=:-.=1_in¢Act(GL152,n 1(5)� fVLic�6an by e bomeoava for e trexx or permit r=y--rd—the
IcIPl ctaau of ea r*oyx uodec din Work s Coa4 av Lioa AeL
1 uD4=L nd tba a oopy of tbi.rw.® cv.y be fo,,ded t.o tbo Dcpcctmcnt of i-j"i icl Accidca&offioo of tnauzaoo for Lb.
oovcrtrgc va-i(crlioo and U-L•iJtac to s=uc covcrnsc adcr SoC On 25A of J.(OL 152 c-,^1a.d to tJ-i- ioa-f--l-1 pcn. -
ooaiixcn of►Ciao orup to S 1)00.00-0- of up to roc ycw end viva pmal'uo rn be form of e Sip Work ordu and e
rim of 5100.00 1 day epiaA 03,_
For dcp.n -"---•t u+c Drily
dePCTMt NlltI L--r_4 p:; Lo(Siena( of L.CCriSCt/[�c[TTU LICG
4'Stt�►+�lP1O
O
LrztV of Xart4antptan
Z =
� � �fassxchiTSetfe
5T DEPARTMENT OF BUILDDNG INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction sup::-,- Sor. The stale defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two family
divelling, 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, /�-, A understand the above.
(Home ow er/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
j ► 3]d,J
Address of work
location ✓-
/'��� `o 66
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Reti stered'°HtsmeTmarovement Ciin#ractor;° f Not Applicable ❑
Comoanv Name Registration Number
Address Expiration Date
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...... ❑
.....................................................
.....................................................
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.Aperson 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 a d Local Zoning La and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Alteration(s) Roofing ❑
/ Windows Or Doors
Accessory Bldg. ❑ Demolition® New Signs [ ] Decks her[ ]
/C o� ik
D' we -' ..\' mac. ;tip\�;� c� e � r.JC CS. ar cd 'vJ�\\
Brief De_scription of Proposed. \ � �' S\7
Work: J
Alteration of existing bedroom_ Yes No Adding new bedroom_ Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0-Sheet
6a: ilEesi�r:FEt�usei ani'E=tiir ai#I L ft�ii�:to: #sf :#uatt5i ':ir�oiri #e� f >�ogaii##i�'
a. Use of building : One Famil 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? Fire ces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck ergy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction ithin 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, ^G` as Owner of the subject
property
hereby authorize kc"t1i\� (-�c:SS to
act my behalf, in all m tters relative to worK authorized by this building permit application.
Signature o owner Date C4113 1 C
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 ins and p alties o perjury.
Print Name i vim\
fA L 6
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LA ' K OF 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 %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Pe it/Variance/Finding ever been issued for/on the site? i
NO DON NOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Regi of Deeds?
NO 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 Conservat Commission?
Needs to be obtained Obtained , Da t ssued:
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:
T' R
City of Northampton
Building Department
r in Street
., 100w
= North n, MA 01060
� AUG pUe -5 0 Fax 413-587-1272
LaA.. PPLICAT>GOO[ ji CT, TER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Progerty Address: This section to be comp
ileted by office
unit.
Zone_ Overiay District
Elm St.District CB District
SECTION-2-PROPERTY'OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
GOvA 3G 0 40
Name(P' 0-3 Current Mailing A ss:
dm 6 _
Telephone L C
Signature lit -
2.2
Authori Auent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed b permit applicant� B„ilding �"�� "' " � ' (a) Building Permit Fee:
f3 000
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) Check Number 41<0
This Section for Official Use Only
Building Permit Number: 05" a Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2005-0255
APPLICANT/CONTACT PERSON BIVONA GARY F
ADDRESS/PHONE 36 DAY AVE NORTHAMPTON
PROPERTY LOCATION 36 DAY AVE
MAP 25C PARCEL 070 001 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: REBUILD EXISTING PORCHES(SAME FOOTRPINT)
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 F9LLOWING 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 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 Commi . n
Z�
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.
36 DAY AVE BP-2005-0255
GIs#: COMMONWEALTH OF MASSACHUSETTS
Ma :13 ock:25C-070 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-2005-0255
Proiect# )S-2005-0321
Est.Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Homeowner as Contractor
Lot Size(sq.ft.): 44431.20 Owner: BIVONA GARY F
Zoning:URB Applicant: BIVONA GARY F
AT: 36 DAY AVE
Applicant Address: Phone: Insurance:
36 DAY AVE
NORTHAMPTON MAO 1060 ISSUED ON.8131104 0.00:00
TO PERFORM THE FOLLOWING WORK.-REBUILD EXISTING PORCHES (SAME
FOOTRPINT)
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 8/31/04 0:00:00 1342 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
ro �
�.,..,, z .. ..... .,� LL..
Toy
CLAMS
I AP
hot ,
` f�XA g
4K T
Kid
CMOs -
� y µvii fF"
� .
36 DAY AVE BP-2005-0255
GIs#: ' COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-070 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-2005-0255
Project# JS-2005-0321
Est.Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 44431.20 Owner: BIVONA GARY F
zotzinz T-7RD aralir_ant: RLl Q(N A CA R.Y F
AT. 36 DAY AVE
Applicant Address: Phone: Insurance:
36 DAY AVE
NORTHAMPTONMA01060 ISSUED ON.8131104 0.00.00
TO PERFORM THE FOLLOWING WORK.-REBUILD EXISTING PORCHES (SAME
FOOTRPINT)
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: , � � k
Driveway Final:
Final: Final:
Rough Frame: jA
7 Y
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Fi r.:t 1: Smoke: Final:
car' ze K
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATIO OF
ANY OF ITS RULES AND REGULATIONS.
t
Certil irate of Occupancy Signature:
FecT tie:_ Receipt No: Date Paid: Check No: Amount:
Building 8/31/04 0:00:00 1342 $50.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Building olnmissioner.-Anthony Patillo