17A-214 J; nassaci�usc:!e �I_i' �y'/
DEP��TMZINT OF BUILDING INSPf=I ONS
12 Main Street * Municipal Building
1 N S P ECTO P Northampton, MA 01060
M)ME f0I1;VN-'JER -LEXIEMUPT-10INN ACICNOWLEDGEMENT
The State of Massachusetts allows the homeowner the rialIrt under 780CNa 108.3.4 to
act a--clrisaler construction sup,��: ::sor- 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
J'weHing, attached or detached structures accessory to such use and/or farm structures. A
person constructs more than one home in a two-year period shall not be considered a
person who constr
p
owner."
The building department for the City of Northampton wants any person(s)who seek to
Oir
use the home owner exemption, to act, as dheir own constractio"n supeerwiso., 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 back-fiJI ).
sonotube holes (before pour). a rough building inspection (before work is
caacealgp. insulation inspection (if reguired) and-a-rInal-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 6ccupancv
uxaU-the wo-rk-Ean 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 buildinc, permit issued, and that they get their required
inspections. Failure of the individual trades to se=e the permits and inspections as
required can DELAY 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
77ie Commonwealth of!Y_fassachasetrs
— Departmeni of IndustriajAcc_='dents
OJiice of In vesiig ations
600 Washington Street
Boston,31,1 02111
'�,y www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Elec.tricians/PIumbers
applicant Information Please Print Lesribly
?Vame(Bi:siness/(Droani=on/Individuai): x ge/e -A)r—
Address:
v
City/state/zip: ��?�'-��'�9►r ()QJ )41i - Phone.
Ayu an employer?Check the appropriate box: Type of project(required):
am a employer with � m a genera 4. I al contractor and I� 6. El construction
employees (full and/or part-time)_ have hired the sub-contractors
T..m r t, the attached er. j_ 0Remode;na
12. 1 a sole proprietor or partner- sled on a . she
These sub-contractors have D
ship aid have no e.�1ey ees S. ❑1�emo,iuon I
worhmg, for me in any capacity- employees and have workers' 9. BuiIdinc-,addition
[No workers' cow.=Suraance comp.II surance.'
required-] 5. 7 We are a corporation and its I O_❑E1ec ical repairs or additions
�.❑ I am a homeowner doing all work officers have exercised their 11_❑Plum,mg repairs or additions
myself. [No workers' coam_ right of exemption per MGL 12.0 Roof repairs
;n.su lice required.]t c. 152, §1(4),and we have no
employees. o workers' 1'-[1 Other
e°s. [lv
comp.incr,rance required.]
xny app rcan cnec Cox TJ tinu2 auo out the se;non oeiow snowta the=work='compEsanon.poiicv muorn=on-
t Homeowners who submit this affidavit indicadns they are doing alt work and then hire outside contractors mus,submit a new affidavit indicating such_
*Contractors that check this box must-attached an additional sheet showins the narne of the sub-contractors and sire whether ornot those entities have
e npioyees. If the ssbsontractors.have a npiovrs,they must provide their work='comp.policy nrmibe.
lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information. /
Insurance Company Name: -r t, d,A, r / X� 60
Policy#or Self-ins. Lic. �, _i Y/s J 17 r I`d i 7 Expiration Date:B��'
Job Site Address:_ y�" �O �,��t j T f1d,01 -AC Z,` /pity/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 S S00.00 and/or one-year i risonment, as well as civ�:l 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
Investizations of the DLA for i=urance coverage verification.
I do hereby certify under the pains and penalties of perjury Char the information provided above is true and correct
Dare Jd 0
Phone j,1167
I
LOther e only. Do not wrzte to this area, to be complered by cny or town oo7ciaL
wn: -- --P--er-mit/License
thority(circle one):
f Health 2.Building Department 2. City/Town Clerk 4.Electrical Inspector S.PIumbing Inspector
rson: Phone
i
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: �'�'�y/N L_ 4-0Z
License Number
Igo 0
Address Expiration Date
Si ature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
,6 91 X- 1J 4� �,p�� z-K)
Company Name Registration Number
Add(ree S Expiration Date
�(),Q7zf#4J1"oP TO A) o1e)6 v Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)j
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 buildin 'permit.
Signed Affidavit Attached Yes....... V 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Wi ows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks IM Siding[[3] Other[❑]
i
Brief Description of Proposed 1 / �x IV cot-,5
Work: [�G°
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 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'
as Owner of the subject
property
hereby authorize
to act on my beh i fl matters relative to work authorized y this building permit application.
Signature of O r 4 Date 0 o-0
4'� �rJ F���` as Own�*r/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.
.�i-l"ns - `
Print Name,
'4177 _ 4
Signature o#- w 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 L: R: L: R:
Rear
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 Q 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 Q YES Q
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 1 NO Q
IF YES, describe size, type and location:
E. Will the construction activity disturh(r_.laaring, grading Pxcavation, 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.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
1 212 Main Street Sewer/SepticAuailabili#y
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
s � Goh`one 413-587-1240 Fax 413-587-1272 Plot/SitePlans
Other Specify
r ` b�PPLICATION TO CQJS.TR.h1CT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
�L �� �p�t ! Map Lot Unit
/i/J �Nr,/L �U,4 0)�Ir� �"' Zone Overlay District
/" Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
l�r9v/ z yo
Name(Pr' Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: L 8
Name Print) Current Mailing Address:
7
'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
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6._Total=11±2±3 Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/InspectorofBO mgs ate
BP-2008-0539
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cagy: BUILDING PERMIT
Permit# BP-2008-0539
Project# JS-2008-000818
Est. Cost: $5300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq. ft.): 24611.40 Owner: LYONS PAUL A&MARY T
Zoning: URB Applicant: B & R Siding
AT. 140 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:1112812007 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 11/28/2007 0:00:00 $25.0021092
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo