25C-143 ¢Z1v�1nT j�
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w DEPARTMENT OP DUILDFNG INSPECTIol.'S —
212 Main Street ' hfunicipal BlIdding
Northampton, Nvfnss. 01060
NV O MCE R'S C O'NT E N S A T7 O N M S URAN CE A F M A VI-l'
I, �i✓77-f G�,�' �,��-G-G�
(li ccusxJpern�i flee)
wlLh a PI-Mcipal place 0f business/residence at
(ph 0nCFO --.57d-?/- 137 �
(aTcz-t/c�tY1S121c 1zjp)
do hereby cerd_f);, under the pains and penalties of perjury, .hat
( ) I aln an employer providing the following \vorkcrJs comnenscdon cove mge for Inv
etupiovices Wor�Dng on this job:
(Insur-an= COtrr,;.nv) (Po Li c-. ?,u_-abcr) --- :pir�tior Dace)
( ) I am a sole proprietor, general contractor or homeowner (ci cie one) a-0d have hired
the cone actors listed below who hive the folloVvUlg worker's coEi:Den-spaon policies:
(I+;Mlle
of CO_^.!^ci0") ��I1 R!f�3nt'..f COIT1D1r1)'/•2 GIJ C'f ?�'tlill�<;) -- j2_ti)li�:]QP. ��ltC)
(N_rnc OI Contraclor l -
. ) (tnsaranc: ComDaa`vPo.IC)� \�ttnc�r) ���>ron Date)
(Name of CoaEmclo,-) (Insuranc: CamPao)•/Pol q- Nzim r) (E\airaoo Datc)
(Name of Contractor) (Innlran Court a>sy/Policy Numbs) Z\Pu-,,6on Date)
(aQa.011 ad'!i�ocal c'uri irncc�i�-)to mcu inform.aoo p<itinans to.11
( ) I am a sole proprietor and have no one worL-ing for me.
(}� I am.a home owner performing all the work myself.
NOTE:Pl—be evrart t!c1`L^Jc`b�_c—a-�co_���—70�cr-s"tbo cmplay p=ow w(So •*-i�-,,,,^.�c��c� c repair.�oric on.d..cn-Z of
aD(-LLD tit'd- r'..t to leh] the WI3XJCl�'�1)CS resid�Or 00 the(�-OUDCt,.)Zpputleasrl Lb-- e..T nat fatly oc,=-d=-d In be
cavploy—urwj. Lhc—kces ccm(c=,�_iica,Act(GLI52=l(5)�Nvlica.600 by a bomcoaarr far.-bc=—,.cc permn r=y--rd—(I-
Iegzl rtaSU of nn-M loyx under dro wociro .Conapomil !ot_
I uo&rrtiod slut a copy of this mt®mt m.y ba for�.avej.d to tbo Dopnr_,of ln�iel Aoodc�•!Offioo of Lo— o for tho
cov-xbc ycrific1lioa m ro Flu U-6m to scauc bovctnsa undo suction 2 S A of MG 152 c m Id to tl>c imoosdioo of criminal pcn+WCS
c0au- itzg of a[UK of up to S 1}00.00 wWd o(up to one yc end a%il pmaf'ao.tx form of n Stop Wori;Ord-rind e
Gm of S I DO.00 t day Lptiwx tcr-
A14� For dc9.rtrnw�u.c only
/ " Lot .i
Signature:of canittct J
��HAMpl,
of Xart4ainptan z =
$ � �lassach�rsctts -
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�^ DEPARTMENT OF BUILDITjG INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
,r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction supc::.•isor. 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 x - ,L ,
understand the above.
(Home owner/r dent's silature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date 7 _4 0
Address of work
location
Ai
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
. R iiti om venit-con �'ctor• _ Not Applicable ❑
Company 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.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 nd State of Massachusetts General Laws Annotated.
9
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement l Alterations) ❑ Roofing ❑
Windows Or Doors Q(
l I
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ j Other[ ]
Brief Description of Proposed
Work: k�> 1,4C C b0 c> [`-/2 U.�1 % cs c►�"1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll❑-Sheet o
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: s�1 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. Mascheck 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
as Owner/Authorized Agent
hereby dec are that the state ents and infor n on the foregoing application are true and accurate,to the best of my knowledge and
belief.
Signed under th=7wamr,and penalties of perjury.
/= ��4i6-'.7
Print Name
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side 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 DONT KNOW ly YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry 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 Conservation Commission?
Needs to be obtained Obtained . Date Issued:
C. Do any signs exist on the property? YES NO X
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:
�Je u�°° 'r
Northampton ��, '
a u Department v�
Y 8
am Street
m 100
JUL 3 0 Nort am on. MA 01060
phone 41 - 7-1 0 Fax 413-587-1272 ,A^ �
CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
i.i Property/Address: (� This-section to be completed by office
V 74. Map Lot,° �init
Zone Overlay District
Elm St-District C8 District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Pr Current Mail' ?Address: -
/� J�
, 7
i Telephone
Sign ure
2.2 Authorized 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
7" d
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
This Section For Official Use Only
Building Permit Number:
Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
39 ORCHARD ST BP-2005-0116
GIS#: COMMONWEALTH OF MASSACHUSETTS
Ma :Block:25C- 143 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ALTERATION BUILDING PERMIT
Permit# BP-2005-0116
Project# IS-2004-0337
Est. Cost: $4800.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Grouo: Homeowner as Contractor
Lot Size(sq. ft.): 7666.56 Owner. PIAGGI ANTHONY&
Zoning.URB Applicant: PIAGGI ANTHONY &
AT: 39 ORCHARD ST
Applicant Address: Phone: Insurance.
39 ORCHARD ST
NORTHAMPTONMA01060 ISSUED ON.7/30/04 0:00.00
TO PERFORM THE FOLLOWING WORK.-REPLACE TWO FRONT DOORS
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 Sianature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 7/30/04 0:00:00 1780 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo