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DEPARTMENT G. BUILD r F
Z�G IIVSP�r.TZONS
(NSPECTOP 2I2 Main.Sweet 0 Municipal Euildng
Northampu7n, MA 0I060 y` `
HCD- E ONVINER EXELIMPTIUNI ACILNOWL DGE jyTE,iT'T
The State of Massachusetts allows the homeowner the right. under 780C MR 108.3.4 to
act aE z,
:,Z/her construction sup,-., i or. The stare defines "I omeowner' as, "1?erson(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 supervio; to be aware
that by doing so you become responsible for compliance with state building I codes
and regulations_ The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before back-fill).
sonotube holes (before oour). a rough building inspection (before work is
cork€.-fled) insulation inspection (if retmired.) and_a_f'in.aLhutldin.insnection. 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 Ean-be-insbected..
If the homeowner hires other trades to peform 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, 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. y
Date
Address of work
location
� The Commonwealth oj'Massachuserts
Department of In dustrial accidents
--.. r�
1„ Ozce of In lestig ations
600 Washington Streei
--,'o—
�' ,a Boston,_114 OZIII
www.mass gov/dia
Workers' Compensation Insurance A-ffidavit: Builders/Contractors/Electricians/Plumbers
ADDIicant Information Please Print LeQiblti
Name (Business/Orzanizadon/Individual):
Address:
City/Stabz/Zip: Phone.,—=,
Are you an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1.❑ I am a employer with 6. []-New construction
employees(full and/or part-time).* have hired the sub-contractors
I ?. I am a sole proprietor or partner- listed on the a=ched sheet_ 7. Remodeling
These sub-con�ctors have D li
i shi.p .and have no P�,le;Tees S. �Lemo,�uon
i workiag for me in any capacity. employees and have work--n 9. Building addition
LrNo workers' o :=s-=-nce comet.insurance*
required] y 5. L1 77e are a corporation and its i 0Z,?Elec=--cal repairs or additions
0.❑ I am a homeowner doing all work officers have exercised their l 1. Plumbiag repairs or additions
myself o workers' co 113p_ right of exemption per MGL
� � c. 1 f2, 1 4 and we have no 1�Q Roof repairs
insurance required.]t § ( )�
employees. [No workers' I-,ED Other
comp.insurance required.]
appiican c ,cs oox F.tract also n out me section oetow saow=g en-worker'compensation.policy information.
Horneowners who subTnit this affidavit indicating they are doing,all work and then hire outside contractors rnust subunit a new affidavit indicating,such.
*Contractors that check this box ra=zttached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
e-npIoye-.s. If the sub-connacrnrs.have emgioyes,they must provide their worlc„zs'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
vzforma�on.
Insurance Company Name:
Policy#or Self ins.Lic. M Expiration Date:
Job Site Address: C:Y/State!Zip:
Attach a cony 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 S 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 5250.00 a day against tle violator. Be advised that a copy-of this statement may be forwarded to the Office of
Investizations of the DL4 for irz u=ce coverage veriucation-
I do hereby cert<fy,under the pains andpenalties of perjury that the inforrnazion provided above is true and correct-
Date: '
Phone#-
I ,
.11 02TLciai use orziy. Do not write to arts area, to be completed by cizv or town 91f7ciat
City or Town: - — -- -- -- - - P--er-mitlLicense
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 Sgp�rvisor: Not Applicable 0
Name of License Holder:
1:17'e.4- License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Coritractor
Not Applicable 0
CompanV Name Registration Number
Address Expiration Date
Telephone
SECTION 1.0-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.,
L,-Home Owner Exemption
The current exemption for'homeowners'was extended minclude one(1) m *wo(2)families
and to allow such homeowner to engage an individual for hire who does not possess ulicense,provided that the owner acts
Homeowner:as supervisor.CMR 780. Sixth Edition Section 108.3.5.1.
Definition of 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. .
Such"homeowner"shall submit to the Building Official,on a form acceptable to,the Building Official,
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 io issued.
Also hcud�viuodthat 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 5orpnmno(n)
you hire to perform work for you under this permit.
The undersigned^hn,ocoworx^certifirs 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
r
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks (M Siding[0] Other[O]
Brief Description of Proposed
Work: L" ]
Alteration of existing bedroom Yes _No Adding new bedroom Yes `^ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a- If,-New house and-or-addition ta-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 I City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize \ l ri C5A
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signat a of Ow Date
N1 1I CGa f e/-� L l�l�t �- as Owner/Authorized
Agent hereby'&clard 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 e o 0 n r/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 m _
Frontage _.. . _. ,.._.
Setbacks Front
Side L: R: L: R:
Rear
Duilding IIcight
Bldg. Square Footage %
Open Space Footage _ ._. %
(Lot area minus bldg&paved
oarkine)
#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 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 0
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 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 U NO
IF YES, then a Northampton Storm-Water Manag—eryient Permit from the DPW is required.
Qepartment use only,
City of Northampton Status'of Permit
Building Department Curb CutlDnveway Permit
212 Main Street Sewer/Septic.Availability
Room 100 `NaterMell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 itla Ff`
'Qty r S '� l
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMpUSH A ONE PR TWO FAMILY 6WELLING
.,
SECTION 1 -SITE INFORMATION
Th- eption t4 4pigprrolot&!by o ice
1.1 Property Address:
Map Lot Unit
Zone Overlay District
Elm St District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�'y j.
Name(Print) ' Curre—nt Mailt49
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
completed by ermit applicant
1- Building !,' 7 r } (a)Building Permit Fee
r�
2. Electrical ^ y (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
r
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number issued:
Signature:
-- --- --- ---- -
BuildingCommissionedlaspeeYoi-of�i mgs- Date
File#BP-2008-0521
APPLICANT/CONTACT PERSON Kevin O'Brien
ADDRESS/PHONE 167 Main Street Leeds 586-0741
PROPERTY LOCATION 23 HAROLD ST
MAP 12C PARCEL 067 001 ZONE URA
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: KITCHEN AND BATH REMODEL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 081383
3 sets of Plans/Plot Plan
THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved J 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.
al ti!�
�o
s ol-e 140
23 HAROLD ST BP-2008-0521
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C-067 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: BUILDING PERMIT
Permit# BP-2008-0521
Project# JS-2008-000788
Est. Cost: $15150.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class:_ Contractor: License:
Use Group: KEVIN O'BRIEN 081383
Lot Size(sq. ft.): 10193.04 Owner: HARRINGTON MARGARET L
Zoning: URA Applicant: KEVIN O'BRIEN
Applicant Address: Phone: Insurance:
P O BOX 183 (413) 296-4511
WILLIAMSBURGMA01096 ISSUED ON:1112012007 0:00:00
TO PERFORM THE FOLLOWING WORK:KITCHEN AND BATH REMODEL
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: vice: Meter:
Footings:
Rough:—/g —01 o5,:ugh: .1/Jc,/b7 House# Foundation:
f �J��, llriveway Final:
Final:��-t Q'()8 � �c,U�D`�"' Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:eK I�'I g-o
Final: Smoke: Final: iq y< � '? s' e 8' ''d
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 11/20/2007 0:00:00 $50.00488
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Building Cormnissioner-Anthony Patillo