25C-263 (2) �'l+e -eomvno.u..ra��i o�,./�,cuoac�ivaella
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 064587
Birthdatg; 10/20/1959
Expires, 10/,20/2008 Tr.no: 2795.0
Restricted...00- '
LAWRENCE F SAWU
LA'
73 PLAIN RD ? ��
HATFIELD, MA 01038 '
Commissioner
LEPAR _;:_NT GF BUILDING L• SPECI ONS cry;
Vic! i
212 Main S crest 40 Municipal B uilding /-F
NE P-r-C-TOP Nortbampton, MA 0 1060
TTs-yiii, (NV.17N7VID VVVAT-V-rTn7NT AI-V7VnWT,RDC-EMENT
The State of Massachusetts allows the homeowner the right under 78OCNa 108.3.4 to
C
1-1- state e d efines "Homeowner" as,
act as 1EIS/her construction SUP- -�cr. ' ., aL
s
who owns a parcel on which he/she resides or intends to be, a one or two family
dwe.0h 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."
Tne building
,-department for the City of Northampton wants any person(s)who seek to
use the hoine'owner exemption, to act as thew`own construction super is-c.-I 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 backdill).
sonotube holes (before Dour). a rough building inspection (before work is
concealed). insulation inspection (if required) and-aTinal-buildinzinsDection. The
department building g . requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
u-nffl the wart;pan-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 DEIAY the project until such time as the proper permits and inspections are
made
L 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
The Comrnonwealih of Massachusetts
_ Jepan.ment of Industrial accidents
0- of Investigations
= i 600 W ashin on Street
Boston,314 02III
~ � www.mass.a ovli a
Workers'Comnensation Insurance A fidatiZt: BuildersJ Contractnrs/Electricians/PIumbers
ADDlicant Information / C _ Please Print Legibly
Name (3i:siness/OrganizaIIorvTndividual): / awy-en E, K3 u_,L)l f—C
Address: �Y\
city/state/zip: Ift, 01038 Phone.=: lfcl�,
Are you an employer?Check the appropriate box:
Type of project(required):
4. I am a Qeneml contractor and I
1.❑ I=a employer with � 6. ❑New construction
,employees (full and/or part-time)-* have hired the sub-contractors
2 _ I am a sole proprietor or partner- listed ene attached shee± 7. ?emodeling
ship and.have no employees T7iese sub-contractors shave g. 7 Demolition I
employees and have work-en'
worlting for me is any capacity. i 9. (17 Building addition
[No workers,co.�.y.irstu�ce comp.insurance.-,
required.] 5. ❑ We are a corporation and its L00 trical repairs or additions
:.❑ I am a homeowner doing all work officers have exercised their nbne repairs or additions
myself. [No workers' comp. right of exemption per MGL f repairs
insurance required.]t c. 152, §1(4),and we have no employees. [No workers'
Comm.insurance required.]
MaLcmecks DOZF,.l n7IISt a:sa nil out me se:aon oetaw snowtng tber workers'earapetsation poiiev ituormation. -------
''Horneownm who submit this affidavit indicatinz they are doing all work and then hire outside conn-a ors must subruit a new affidavit indicating such_
*Contractors that check this box tnust.attacbed an additional she- showing the name of the sub-contractors;and state whether or not those entities have
etrmioyees. Y the sub-contractors have erttpioye s,they must provide their workers'camp_policy nuaf .
I am an employer that isprovh ng workers'compensation insurance for my employees. Below is thepolfcy andjob site
fnformadon.
Insurance Company Name: —
Policy#or SeLf ins.Lic.r:• Expiration Date:
Job Site Address: City/State/Zip:
_4ttach a copv of the workers' compensation policy declaration page(shovrina the policy number and expiration date).
Failure to secure coverage.as required under Section 25A of MGL c. 152 can lead to the i=osition 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 ORD>✓'??and a 5-me
of up to$250A0 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
In vesti_adow of the DL?for insurance coverage verification
I do hereby certify u der the Darns and aloes perjury•that the information provided above is true and correct
ate: 8 _
Phone--:
i
vjT4cfal use only_ »not x rate i7 th area,tb tier cDnrpleied Lv y ur/own o ciaL
City or Town: --- ----_-__ _ __ -- _- -- - -- Permi#/License
Issuing Authority(circle one):
1.Board of Health 2.Building Department City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone=:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: &�o )y� Not Applicable ❑
Name of License Holder: L+ k-4j:j p 1' `
License Number
Address Expiration Date
� %0/alr la 8
Signature Telephone 7638
SoReoistered Home Improvement Contractor: _ Not Applicable Iii/
L. f4 W
C7—IS-C—I VI"V 114
Company Name Registration Number
Address Expiration Date
7 I 11`Te�p one
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....... W 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-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 \ n vn
r
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ff7Roofing ❑
Or Doors []
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [[] Siding[p] Other[l/
Brief DUccr�ription of Proposed
Work:I'�i'!'lidi/'r �c1CS��r��-�► � an� � � ���' L>,l�'�1'\��-��
Alteration of existing bedroom Yes L,� No Adding new bedroom Yes _ No
Attached Narrative Renovating unfinished basement Yes 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?
i I
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, J O n 4'X'4�l�N "'Q �A as Owner of the subject
property
hereby authorize .NrT-U-a:t C— Lo
to act on my behalf, in all matters relative to work a horized by this building permit application.
Signature of Uner 11 Date -
as Owner/Authorized
Agent hereby dec are that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Sign pains and penaltie perjur
Print Name
&Oln�Foce t 130%
Signature of Owner/Agent Date
s
Section 4. ZONING AU 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 lcJ '- 5
Frontage
Setbacks Front
Side L:49d) R: f L: Q R
I I
Rear AS
Building Height
Q�
Bldg. Square Footage G 00
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 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW 0 YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO � DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q Date Issued:
C. Do any signs exist on the property? YES 0 NO J
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 constr1_in.tinn activity riiSfijrh(clearing, grading, excayation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
BOi,lding Department Curb Cut(Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
,hlorth .mpton, MA 01060 Two Sets of Structural Plans
phut ,413-58,-1240 Fax 413-587-1272 Plot/Site Plans
Other;Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
01,,57 O ! d iFRR ��. Map Lot Unit
N o QT A A M�T/V, /1'),�gs, Zone Overlay District
oio�o
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED ;W7
2.1 Owner of Record: As- 0
Jo 4 n -I- k A R 6-ry r* a AlA IV o Q-rh#4 ►N ,OTN. SASS m i o 4 o
Name(Print) Current Mailing Address:
Telephone('f Ci� 70
Signatur a
2.3 Authorized Agent:
Name(Print , Current Mailing Address:
ignature 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
Construction from 6
3. Plumbing Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total= (1 +2 +3+4+5) Check Number 3 3 Csd
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Budding Commissioner/Inspector o�Bui mgld s Date
File#BP-2008-0706
APPLICANT/CONTACT PERSON BOBALA JOHN J&KAREN A
ADDRESS/PHONE 25 OLD FERRY ROAD NORTHAMPTON Q 586-2704 Q
PROPERTY LOCATION 25 OLD FERRY RD
MAP 25C PARCEL 263 001 ZONE SR/WSP
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:_REPLACE KITCHEN CABINETS
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOVAIATION PRESENTED:
pproved 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 Commission Permit DPW Storm Water Management
Demolition Delay
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.
BP-2008-0706
GIS #: COMMONWEALTH OF MASSACHUSETTS
owl '74
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
11cr„ir. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category BUILDING PERMIT
Permit# BP-2008-0706
Project# JS-2008-001090
Est. Cost: $7200.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Lise Group: Homeowner as Contractor
Lot Size(sq. ft.): 142441.20 Owner: BOBALA JOHN J&KAREN A
Zoning: SR/WSP Applicant: BOBALA JOHN J & KAREN A
AT. 25 OLD FERRY RD
Applicant Address: Phone: Insurance:
2� OLD FERRY ROAD 0 586-2704 (�
NORTHAMPTONMA01060 ISSUED ON:212212008 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE KITCHEN CABINETS
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:
FeeTvpe: Date Paid: Amount:
Building 2/22/2008 0:00:00 $50.003315
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo