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ci DEPARTMENT OP BUILDrA'G INSPECTIONS
212 Main Street Muoicipal Building
Northampton, Mass. 01000
«rOR1Q�R'S CO NI. ENSATTON 1MS 7RA-NC'F- AI`1.1JJAWJ'
77
v-11th a pli,-Icipal place of businessfresidenccc at-.
C) b C�l J . , (phone-*-)-�
s>?-�tici t}/stattTZ3 p)
do hereby cerdi --, under dic.pains and penalties of penury•., hat
O I am an employer providing the following \vorker's colnnensaao, coverage for lny
emplovcc;s working on Otis job.
(Lamy--n=Comm-n--) (Polio:?vu--nbcr) --- (xpirlSor, tDzu.)
I am a sole proprietor, general contractor or hotneo�'rmer ale one) and have hirea
the cona�actors listed below who have the follol- f'er s cocpensztion policies:
tiV'Gi IleI wu SO IZ° /P0PTFt,,00
('la M: O. C0-D!MCi0:'1 (111--u mncz CoinDan)- Ouc T�iaQ7-<:) �t-';:)did=^R D 11C)
(Dame of COaQ3CZor) �- (lnsarancc ComDaav/?olic-v \tumor) (Expiration Date)
(Name of Conaacto;) (Insurane:C.ompanytPobcy Numbcr) (Expiraoa Daic)
(Name of Coatraeior) (Insurance ComDarylPoLiey Numbzf) (Expi-,ioa Date).
(aasch ,rnooc ry w mclud;raformzioa P=I ia'g ball Co=-_Con)
1.
{ ' I am a sole proprietor and have no one work-hg for me. t
( ) I am.a home owner performing all the work myself
NOTE:PI=-%.c be a-:trc the-k'Ije hoc owo-ra w.bo aaplay p.=r w&m.:,Doc c=.,r a c-rcpz;r worX on.d-1L:�of
aDt mote tb=t.t:roa tmts to K$icb ttx .do or oo the E7vUDdn zapurtca:rs theeo 1-c not '-11y oeerd=cd w be
—vloy—a �c the--k o=2p om Aa(GL152n 1(5)} :pplica600 by a bomcowoa far:Gex_.or Pamir r=Y c idaD«the
1cg ttsnu of as-=ployer uoder duo W"k ol,C,oa=poosation Act
I uodc d&A a oopy of chi,crt,=mm o y bo for xnrct.d to tbo Dryartmcot of 3odus_ricf/n�d��Otfioo of 5 +�lot t)b
mverabc vrrif estioo aced 11x:1 C11ta,c to smtrc bo�crasc uadct suction 2SA of 1.10E l52 con lad to tba impotiiiw of eiminzl pcnaltin
comisixts of a fine of up to S uoo.00 artdroc bxgxjjo=DCMj of up to ooc yr=LDd 6%il pmaPIja io 6,form of a Slop Work Order nod a
fiw of S 100.00 a day ap,inst Mt—
For dcp"trz'`_'1 u.c only
Pcrmit Nu ml--y
Lit A.
siitacun of Li — -,
q„•Ct1AMP�.
g�� oyg (rity of Wart4 imptan L Z
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I�AS6AC�f]IStftS -
uun -
DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR 212 Main Street 0 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 i.is/her construction sups:.:nor. 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
r f understand the above.
(Home owner/res ent'` 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
� E (1,xfhJ Ll� �1LTZ'�liiil]l�Jft1I1 � �.
6 �3�[S�ftCli tib Ctl7
w
M m L)EPltRT1.,Elrr OF EUILDDI G INSPECTIONS
212 Main Street * Municipal BuilcEng j
Northampton, Mass. 01060
WORICER'S COMTINSATION A MAN1T
- - (Ilccr.:"_ti`�CIII71iicS)
�,'ith a princip'd place of busiresslresidenc
(phone=�'
do 11e1 cby CC>L1I�', 1I:7:i' r 1110 h%iil$ 3ii7 OCil it1CS OI pCf�11f}', lrli!!.
I am an employer providing the follov.inC v'.o!-r;crS Col19pcnsS'uon covei'a111,C 1*01 Il1y
employees wor�dng on this job:
(Insarana Company) (Ex#r tion Date)
( ) I =i a sole proprietor, ze,-trai hor co-v-�-ce: (cicle Oct) and :.2ve hired
the contractors listed beiov-, ;,`1'o i; 'Lh]° 'o11c vL;r •vjoFkPrS Ccmot]�3uort
(Na-Mc of Contactor) (Ins'u _nc Nu-mbcr) (� ` :aon D<>tc)
(Name of Cont ctor) (.712su _nce CoTI� ,:v[Pc.! Ntrnrrr) (1: ,aion Date)
(h amp of Cowumclor) (In;I �sx C.,n-t c, a txr) =.z, r dc_ Date)
(Name of Contactor) - (IDS�ratic; Corns,:_.}[Paliry Numttir'l) (I:;:pi ::io-:Da(e)
an) a ,;Ulc prop!c"Ji i1:"J ili:'v' no 01: /ii` t0r inn.
( +� !?i11 I? ho;mc CW?1er iiCi:Cl`IIl1P. ?11 iL
NO"f�I::please lti a•.5-1;c t!�s:•.vl:i]c txtr�a•.v1m w`ro r�i��;>=:��;n:'.>�.::-•;•�^cc.cZ>:r_:,:wm cr:c(:air«,,:i_s-::�.�clL::�c.
not rice than throe unit ir.%,-;cr he rc: 'w a; z_.•=r cr�r'L cote c c r 4 rc-tcsall.i
per;:i:r cr�c
cv*.ployv-3 ur�'tfr.,w:�_a's c�::--:_ice r�t:(c-r i.'.S?�`:(�l?.a,:�':ic_:ic::]�y a t:ntaro..�w`cr e .-
Itgal natuc of an omployex un(�er tvc WcYkcr.Co,2,xr_• Zion!'xL
I un<&-_ztx d IhL a Copy of the bo fo,---d-J to t_' Dctxin_-xr e of lndtutrinl Azci& &01'5b of i:` of
llx
COVC77l�t vQ7I1 0..2304 aild tlt_•t L.ilure to:a.:..:e eo�-r ;un3::.c�.ic^25 n,et'•.;GI.1 S2.czn Ic�ti to tlx im�siiia�ot c:��
comisli tg of a fur_of up to S l_SM0o a:
SECTlONB-;CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: 1 Not Applicable ❑
s � A � 1-e 1 W`�1/� U ,
Name of License Holder :�l�l L. ttY�C (,� Q/
License Number
Addres�, J Expiration Da e
Signature Telephone
R-e""g�s eredR! ome"lmproYern ntnCon'° `t a+ter
Not Applicable ❑
Comgany Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS',COMPENSATION INSURANC& FFIDAVIT(M:G.L. c 3.52, § 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 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 fo-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 as rtes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State ancL�lc ,o fn/g`Laws and State of Massachusetts General Laws Annotated.
omeowner Signature �+� Z`
SECTION DESCRIPTION OF RROPOSED WORK(check afl ap lia cableI
w
New House ❑ Addition ❑ Replacement Windows Alteration(s)W Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolitior4 New Signs [ ] Decks [ ] Siding[ ] Other A
Brief Description of Proposed Work: 'ce4-'U rA)V.— , VgLwe
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
Ga If�°New�hous`e�'and�r addi'tion�toezis#Ong==.housingcomp�Fe�e'�he�fol.lowin�
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. bimensions
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 OWNERAUTHORIZATION -TO,BEiCOMPLETED WHEN'
OWNEkS AGENTOR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize ,&C"1'd � �'CLr to act. on
my behalf, in all mat rs rel Live to work authorized by this building permit application.
Signature of Owner Date
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 Owner/ gent Date
R
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Requifed by Zoning
This column to be filled in by
�s Building Department
I
I
L ize
i
Frontage
Setbacks Front
Side L: R: L: R:
Rear
f
Building Height
II
Bldg. Square Footage %
i
Open Space Footage %
(Lot area minus bldg&paved
I
parking)
I
#of Parkin S p aces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO_ DONT KNOW 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
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:
of 'orthampton
BUildi� Department
-� ` 212` in Street
Rbafn`J00
NN Northam ton, MA 01060 T ti
�A
phone 413-587-.f240 ax 413-587-1272 x '
APPLICATIO6 CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This sectwn 46,':completed by office
1.1 Prooe ft Address: a`
2-1 -3 Lot Unit
� µ,
ZO ^OYerlay District.
;;Elm St Distr►ct °"'° � � ,,CB diSd'ICIL -
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Own r of Record: � a P
Name(Print) Current Mailing Addr ss:
Signature
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
2. Electrical (b) Estimated,Total Cost of
r` Construction from 6
3. Plumbing �o e
Building Permit`'Fee
1 . ms
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2+ 3 +4+ 5) (� .s� Check Number
This Section For Official Use Only
Building Permit Number: ^ `�'�"��6 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-1169
APPLICANT/CONTACT PERSON MARCHAND SHOSHANA&LUKE JAEGE'�R_�
ADDRESS/PHONE 30 ORCHARD ST NORTHAMPTON
PROPERTY LOCATION 30 ORCHARD ST
MAP 25C PARCEL 167 001 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: REMODEL KITCHEN&REMOVE WALL
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 FjOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I F 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 mmission
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.
30 ORCHARD ST BP-2004-1169
GIs#: COMMONWEALTH OF MASSACHUSETTS
MW—.$&4.;25C- 167 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-2004-1169
Project# 35-2004-1769
Est.Cost: $6300.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 8319.96 Owner: MARCHAND SHOSHANA&LUKE JAEGER
Zoning:URB Applicant: MARCHAND SHOSHANA & LUKE JAEGER
AT: 30 ORCHARD ST
Applicant Address: Phone: Insurance:
30 ORCHARD ST
NORTHAMPTON MAO 1060 ISSUED ON.•5127104 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL KITCHEN & REMOVE WALL
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 Sienature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 5/27/04 0:00:00 3818 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo