24D-141City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work:'`
The debris will be transported by:
The
debris will be received by:
Building permit number:
Name of Permit Applicant IN-�
I
Date Signature of Permi-Applicant
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INSPECTOR
Louis Hasbrouck
Building Commissioner
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060
Chuck Miller
Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. 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
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 ? y//�
Address of work location f :S F: � 4q 0.
2cx The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
s 600 Washington Street
Boston, MA 02111
. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: I �_E; y1 S1'
Are you an employer? Check the appy
1. ❑ I am a employer with
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. [�am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
v l Phone #:
riate box:
4. E] I am a general contractor and I
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.$
5. [] We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]_
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. [❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12. oof repairs
13. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
tHo meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:.
Job Site Address:
Expiration Date:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under thepins and enalties ofperjury that the information provided above is true and correct.
Signature: ---' _ - -_ _ Date:
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
Name of License Holder:
Not Applicable ❑
License Number
Address
Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor:
Not Applicable ❑
Company Name
Registration Number
Address
Telephone
Expiration Date
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 buildinq permit.
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
/r,haton Ordinances, State and Local Zoni g�L-alms and State of Massachusetts General Laws Annotated.
mp
meowner Signature
LVA
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑
Addition ❑
Replacement Windows Alteration(s) ❑ Roofing ❑✓
Or Doors E]
Accessory Bldg. ❑
Demolition ❑
New Signs [O] Decks [p Siding [0] Other [O]
Brief Description of Proposed A/�
�I%�/f.�
Work: Reshingle roof a , Aane�
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes x No
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
l 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 --�
Signat of Owner/Agent 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
Frontage
Setbacks Front
Side
Rear
L: _ R: _
L:R:
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 (F) DON'T KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
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
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
V
;l f qUU -4 2014 1,
i
eotric, Plumbing & Gas In ne
Northampton, MA 01060 ctions
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
13-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING I
SECTION 1 - SITE INFORMATION
.1 Property Address:
This section to be completed by office
Map Lot Unit
NeVlt ; i �` C) l o G, C!
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Kathryn Reagan
13 Finn ST, Northampton MA 01060
Name (Print) _.... - -
Current Mailing Address: 413.387.9999
Telephone
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
com leted by permit applicant
1. Building
4,000
(a) 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)
4,000
Check Number
Li
1,1146
This Section For Official Use Only
Date
Building Permit Number:
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
13 FINN ST BP -2015-0146
GIS #: COMMONWEALTH OF MASSACHUSETTS
MapBlock: 24D - 141 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP -2015-0146
Proiect # JS -2015-000257
Est. Cost: $4000.00
Fee: $35.00
Const. Class:
Use Group:
Lot Size(sq. ft.): 4965.84
Zoning URC(100)/
PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
Homeowner as Contractor
Owner: REAGAN KATHRYN
Applicant: REAGAN KATHRYN
AT. 13 FINN ST
Applicant Address: Phone: Insurance:
13 FINN ST (413) 387-9999_0
NORTHAMPTONMA01060 ISSUED ON. 8/412014 0:00:00
TO PERFORM THE FOLLOWING WORK. SHINGLE ROOF OVER 1 LAYER
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W.
Underground: Service: Meter:
Rough: Rough: House #
Driveway Final:
Final: Final:
Gas: Fire Department
Rough: Oil:
Final: Smoke:
Building Inspector
Footings:
Foundation:
Rough Frame:
Fireplace/Chimney:
Insulation:
Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Siznature:
FeeType: Date Paid: Amount:
Building 8/4/2014 0:00:00 $35.00
212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272
Louis Hasbrouck — Building Commissioner