17A-128 (2) OEP:�aTME T Or BUILD_'\G Z1iSP�'CTIOCIS =cal
212 Main Suter • Municipal Building !`
INSP-ECTOR
North<unptan, MA 0I060
ROME Oj NTER L.XL NIPTIfl!' ACI'NOW EDGE-MFNT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as l.is/lier 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
ihvelling, 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 thew`Own construction superS:sO; 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/footing's (before back-FIJI ).
sonotube holes (before pour) a rough building inspection(before work is
co-ncealed) insulation-insnectio n (if required)and-a_final_buildina.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-can-be inspected-
If the homeowner hires other trades toper form 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
Address of work
location
Y 77ie Commonwealth oj731assachusetrs
,Department of In dustrial.4ccidenis
Off ce of fnvesti a.*ions
600 Washing-ton Street
Boston,M4 02111
www.mass.govIi is
Workers' Compensation Insurance AfidaNjt: Builders/Contractors/Electricians/PIumbers
Applicant Information Please Print Lesibly
NTaMe (Business/Organza on/Individual): WINDOW WORLD
56 Dimock Street
Address: Leeds,MA 01053
_ 586-8722 - - - -
City/State,/Zip: Phone.-:
Are you an employer?Check the appropriate box: Type of project(required)
4. I am a general contractor and Z
1.❑ I am a employer with 6. ❑New construction
e=lovees(full and/or part-time)- have hired the sib-contractors
1 am a sole proprietor or partner- listed on the ached sLe✓� 7. ❑Remode mg I
Iship and have no loyees These sub-contactors have g- De= on I
wor a for me in an capacity. employees and have wor---n-
y P 9. ❑Building addition
N o work-='cow.insurance comp.insurance.*
required_] 5. [] We are a corporation and its I0.❑Elec'uicaI repairs or additions
:.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself o workers'co imp. right of exemption per MGL
� � 152, 1...❑Roof repairs
insurance required-]t c. §1(4),and we have no 13.7 Other
employees. [No workers'
comp.insurance require,—I]
---' v appncan per oox anLSt a so out inc se non oe:ow snowing thee works'corrocis=oa policy=orm=on.
Homeowners who submit this affidavit iodic adne they are doing all worn and then hire outside contractors mustsubffit a new amdavit indiradng such.
*C.ontracwrs that check this box must_attached an additional sheet showing the name of the sub-contrac-tots and state whether ornot those entities have
e npioyees. Y the sub-contactors have employers,they must provide their wor:kc s'comp.policy number.
I am an employer that is providing workers'comp ensatan insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy#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 MGL c. 152 can lead to the ir=osition 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 one
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
Investisations of the DL?for insurance coverage verification.
do hereby ceCt<f under the pains and penalties ofperjury that the information provided above is true and correct
uate: 7
Ph
_37 7
vfficiai use only. uo not wrrte rn thts area, to be completed by city or town of-ficiaL
City or Town:
Issuing Authority(circle one):
1.Board of Health 2.Building Department City/Town Clerk: 4.Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone T: ;
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 Improvement Contractor: Not Applicable ❑
/d �ObfJ
Company Name Registration Number
WINDOW WORLD 7Z.--O
Address imoc Street Exp ation-Date
Leeds,MA 01053
e 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...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellines 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 buildine 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 Wind Alteration(s) Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [0] Other[[3]
Brief Description of Proposed�— !� "
Work: Y"-'i o 4�I�y�- "IA',
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 behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
y [ as Owner/ uthorized
gen ereby declare that the statements and information on the foregoing application are true and accurate, to the best of my dge
ief.
Signed under the pains and penalties of perjury.
Print Name
Signat —caner/g—e— Date
1A
Section 4. ZONING Alt 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
oarking)
=ofP,,king Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Q YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES Q
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 Q Date Issued:
C. Do any signs exist on the property? YES Q 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 Q
IF YES, describe size, type and location:
E. Mill 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.
R a
Department use only
\,. Bof Northampton status of Permit:
ing Department Curb Cut/Driveway Permit,
12 ain Street Sewe r/Septic Availability
Roo 100 Water/Well Availability
�m n, MA 01060 Two Sets of Structural Plans
-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
PPLICA TO CONSTRUCT,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:
Map Lot Unit
Zone Overlay District.
l Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
2!5�. 4,�7�N s��i` l`Care0-C C--
Name(Print) Current Mailing Address:
may ft ---I—; 3�
Telephone
Signature
2.2 Authorized Agent:
/ L S. 0411 GiGS3
Name(Print) _ Current Mailing Address:
ature 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
0. Tulal- (1 1 c^ 1 3 i 4 5) d 4 6 F ° f hark Niimhar
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
____
Budding Commissioner/Inspector o')^Buirdings -- - Date
BP-2008-0389
Gl 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)
Category: BUILDING PERMIT
Permit# BP-2008-0389
Project# JS-2008-000571
Est. Cost: $5906.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq. ft.): 11412.72 Owner: LAPINSKI EDWARD J&ANNA MARIE
Zoning: URA Applicant: John Corbett
AT. 315 BRIDGE RD
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:1011012007 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 10,110/2007 0:00:00 $25.002699
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo