11C-022 C
21 ,Mzda S Lr!=" "LI y di:1--
HICDOlIff (D.-W-INEERP Ex E,NE�ITION A f--L:Wnv,/-7 DGE-MENT
—E
1 Tire allows 'Lhe homeowzier Le I-,zLz u7 der 780C2,-T, 103.3--,rf to
es OMIC wner"a-E I'a"Soils)
The sz tU,--!v2fz "h'
Who o7,-,-s a parcel on w nic' he!sn e resides or Lt ezds to be, a ore or two
redl or,d,:-:za(--hed s=czurds accaesscr dl fa. S=ctures,
y to such US e an 'Or =
d s� 'dered, a
re one home in a Fer-C :all not be cc=, .L
person W-f--c Con-strua-Z=C,
II
lcrae
5 c S. to
T-he b eF 'e Ci-,-Iv of Nc-rth�-P-lo w-,-z=
supen,:S-,
0 Vmei-eXU�m as their c-,im
tLe -om P"Ga, to aC7,
tLal'bv do so-v-au become responsible for compli=ce with sttafe buEdIng cedes
and re`ufaz-=- The-ins;e--mor, tLal t-l-ne buEld-ing- derzr=ent be called
to izzue-w C1, z7 -es --mch j=,cjTde founder
t - (bef o e b
?Il.
sc-notabe holes f-Defore uourl. n raug-h bu-Rdip:z*h=eCt',orr-(before work is
CCM.Ctilld-d4- iN- t!49-m inzzectiaja (if re--z.uhred)aa- d-2 finny h dinggi=ecd-lan- Tae
i=ecticns before the warns is corxevjed, f2fure to
bu-EdL-22 dep,=e=,T.req=es these
secure thtse fhsuectfGm can result fn failure to obtain a ce--d5ratLaf Occuaancv
Y f e h=e c hires over trades to per o=work(elec-t—ica-1, plu--,big gas) tLe
LG=eo -WE1 b-e rwuGLSiGIa to r-:2-li-le sLre tLat Le tz-azes h.L-ed S&--T-e their Proper-
ern=ts is C'o- uz cE the builldLg pe�=-' and tL!a+tLay gel their required
i=pelZtjOUS_FailLre Cf*lLe i7-- es to szeczzze Le pe,-=:rzs and ir,-7.e--LTGZs as
tr�,-
c �T A_cam:D-7 tl:e proftct. lmtal Such time as ti e and =pec--ions ara-
the above-
(Hpzae' w4p-l-lresidenes Signature requesting emem-ption)
I =mot call to scLedull-a-TIT re-ClUzied m--pecticrs nec-e—sS for fEe build'
to
Office of In vestiaatlons
600 Washington Street
- Boston, MA 02111
www.mass.ov/dirt
Workers, Compensation Insurance Affidavit: Builders/Contractors/E lee tricians/Plumbers
A r:ollc=:nt Information Please Print Leaiblti
Name (Business/Organization/Individual): _
A as
C1Ltull.s J.
Cite/State/Zip: Phone *:
:-`-re you an employer? Check the appropriate box: Type of project(required):
!.❑ I am a employer with 4. ❑ I am a general contractor and I 6 ❑ New construction
employees (fuE. an&or part-time).T have hired the sub-contractor
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in anv capacity. employees and have workers'
9. 17 Building
Q
[No workers' comp. insurance comp_ insurance.?
addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
J.❑ I am a homeowner doing all work ofricers have exercised their 11.❑ Plumbing repairs or additions
myself. No workers' comp. right of exemption per MGL 12.7 Roaf repairs
insurance required.] t C. 152, §1(4), and we have no
employees. [No workers' 13.[1 Other
comp. insurance required.]
`Any applicant that chec.1c box TI must also fill out the section below showing their workers'compensation policy i-nformation.
Ho meowners who submit this affidavit indicating they are doing all work and dten hire outside contractors must submit a new affidavit indicating such_
C 01u,':C'_0rs tl�a: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 worsers'comp.policy number.
I am an employer that is providing worriers'compensation insurance for my employees. Below is the polity and,job site
information.
Insurance Company Naive:
Policy r or Self-ins. Lic. r: _Expiration Date:
Job Site Address: 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 ti1GL c. 132 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5230.00 a day against the violator. Be advised that a copy of this statement may be fonvarded to the Office of
Investigations of the DIA for insurance coverage verification.
-1 do hereby ce , y rrrrdz, rlie pry-rrs-rrfrr e r ties ef-peKjaEr ;rr'rk the information provided above is true and correct
—
of
vS i mature- Date;
---
Plcre= ll3�S�
t,zcial__z��z__r�r1� I?u_�xr,r wY 1[xis_areu toil completed by city or town officia l
City or Town: Permit%License T
Issaing Authority (circle one,: I
I- Bi)1rd 1)1 r_e'a1th _. Bu idln'? De iitn?�nt J. rit+'Tvi�'u Cler;i riiL'tr.L'11 ySpt )i P.L 1✓iTi`_T 1aJit=ii�r
6. otli-e
i i
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Registered Home lmpiovement.C'ontiactor - _, , _ 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...... ❑
ion,
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 individualr 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors 171
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [M Siding [01 Other[01
rief Description of Proposed j 11
Work: / bL 2. 15 N EL S x,�&.ae w1e444-�
Alteration of existing bedroom Yes No A g new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. If New' house aid or addition-to existincl fiousln _comp[efe the fottowinq:
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-Td 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
(jr0-C,ry \7— k, as Owner/Authorized
Agent hereby decl 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
LS ature of Owner/Agent Date 1^/ vim®
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 _w .. .,.,_. .__..... _,,,__...._. _..._
Setbacks Front
Side L:_....._.._s R. __,._ L _.._ R::__
Rear
Building Height --...
Bldg. Square Footage _. _.. % _.._...
Open Space Footage _ %(Lot area minus bldg&paved --
carking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT 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 0 DONT KNOW 0 YES C
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 0
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 0
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 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Departmeh use.oily,•
_ status of Perrrt Ci ty of Northampton
'Building Department Gr, CutlDrtveway=Perrrti
212 Main Street SewerlSepticAvailabitity
Room 100 Wateelftet(Auairabil"
(n�
Korthampton, MA 01060 Two bets Qf Sfructura>Ptarss
ApR Pone 413-5.q7_1240 Fax 413-587-1272 Plot/site Mans
Other,Sp acr€y�
AAPLICATidN T� 6N6TK0CT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SE TION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
mil" �c,.��e—,V-h b K � � , Map Lot Unit
O Q573 Zone Overlay District
Elm St District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Ma}}linq Address: Ims
GO e. Telephone
t' Signature b d YS
2.2 Authorized Agate—
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 O DO0,.o/ (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) Check Number !.
This Section For Official'Use.Onl
Date
Building Permit Number- issued:
Signature:
- - - -- ---
Date
Building Commissioner/Inspector-ofBui ingrd- s
.r
j BP-2008-0856
GIs#: COMMONWEALTH OF MASSACHUSETTS
111 � ' CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate.,ory BUILDING PERMIT
Permit# BP-2008-0856
Project# JS-2008-001305
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 8494.20 Owner: RUSSELL GEORGE J JR&KATHLEEN
Zoning. URA Applicant: RUSSELL GEORGE J JR & KATHLEEN
AT. 7 HEFFERNAN ST
Applicant Address: Phone: Insurance:
7 HEFFERNAN ST
LEEDSMA01053 ISSUED ON:41212008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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: Date Paid: Amount:
Building 4/2/2008 0:00:00 $25.005560
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo