03-021 (12) N N
-----------------------7----------- --------------------
----------------- -------------------------
CS)
A
ril
0
rr T
Z' �7
7
A
Nf, C,106
Ar I)IVNE DGEI),
i-ERAEAD, Ox CEMALE !ENT
7"he State'o1cMassachusetis allows the the 1-I ht under 780C-_,",,a 108.3.-4 to
act as consr-L7cnon sup,.: szar--- s
I iomeowner rson( )
who a parcel on which he/she resides or intends to be, a one or two fa?.-z d-Y
attached or deached struc.::re;s accessory to such LLs.,e and/or f=,-, St:rLctures. A
person who constructs more than one home in a we-year pe.-iod shall not be considered a
home c-7vmer.-
The buildin:z-_de-'artment-, for the City Of Nor-tham p t On 7-ant 5
any Persozi (s)W-1-0 seek to
use riscr to be a7-,;-a:-e
the home owner exemption, to act as tue:7 0'7vM SUp— 25—,
that by doing so you become responsible for compliance with state building codes
and regula-fions. The inspe--tion?process requ-ires that the building depargent be called
to ins-pect work at various stazes, which include Foundation/footings Cbefore bacl.,TMI ).
so-notabe holes (before oour). a rough building insrection:(before work is
co_rxewled. insulation in-spectian (if reauired) amd-A fin-g! LRgdingJ=er_tf0n. The
budilding department requires these Inspections before the work is concealed, failure to
secure these insuections can result in failure to obtain a ce.-tificate of occuoancv
until- he-w-Grik
Z the hameowner hires other trades rlo perform work(electrical, plumbing&.gas) the
homeowner-wEl be responsible to r:al-ce sz-,r--that the trades hired Secure their Proper-
Permdts in conjunction to the building Permit issued, and that they rg
I ' get their required
inspections.Failure of the individual trades to sec-are the permits and inspect.ions as
re J can D-AE"LA Y the prqprole_ un til such time as the proper permits and inspections are
made
iun-derstand the above.
(Hornleowner/resident's signature requestinz exemption)
I,7, , call to schedule all required building inspections;necessary for the building pe.=, t
issued to -me.
Date
Address-,Of_WOnC___
location
i27Ci;'t]�tel�t of�nd��st,"i� 41 CCi de;Zts
- Office of In>>esti;
cations
'
600 t l'ashin-ton Street
Boston, 314 02111
_.._ www.inass.g o v/dia
Workers' Compensation .Insurance Affidavit: Builders/Contractors;Electricians/Plumbers
A onlict.at Information Please Print Legibly
Name (Business/Organization/Individual):
A AA
City/State,Zip: '�`�� C� A Phone
are you an employer? Cheek the appropriate box: F7. pe of project (required).-
❑ I�m a em to er with 4. ❑ I am a general contractor and I
1. p y ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. employees and have workers' q ❑ Building addition
' insurance comp. insurance.-
re o workers comp.required.] 5. ❑ We are a corporation and its 10.F-1 Electrical repairs or additions
❑ I am a homeowner donna all work officers have exercised their 11.7 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] _ c. 152, §1(4), and we have no
employees. [No workers' 13.7 Other
comp. insurance required.]
*Any applicant that checks box rl must also fill out the section below showing their workers'compensation policy information.
Ho meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
°Conu-actors that checl<this box must attached an additional sheet showine 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 workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site
information. _ _
Insurance Company Name: —
Policy#or Self-ins. Lie. EXMTation Date:
2ate\)-
Job Site Address: t 'r� ��k � ��r /Zip�' n;�
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 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DI_A for insurance coverage verification.
I do hereby certify tie-of-p _ -that-the information provided abovejs true.a1V correct.
1
Signature: °i -
" Z .� Date:
/-7
Phone r: � ��
<_ :__�__O�acial_icse-r�rzl�D�_n.oUvute�Zlliis_azert�to be completed.city_or town_of�cial
- City or Town: -- — — Permit/License
Issuing Authority (circle one): �)
1.Board of�Health 2. Building Department 3. City;Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
o. Other l
Contact Person: Phone �*:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
�
,-240
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
41,
Company Name Registration Nu ber
Address Expiration Date
Telephone �4-
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...... ❑
1. - Home Owner Exemption
The cur-rent 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 Windows Alteration(s) Roofing ❑
Or Doors a
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks Siding[01 Other[01
r �3.k v tr,+�t r�i r1 V�0 1T l�4�� r�•v
Brief Description of Proposed 2.
Work: %b
Alteration of existing bedroom Yes No Adding new bedroom Yes SZ 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 f
c. Is there a garage attached? °3
d. Proposed Square footage of new construction. Dimensions
a
e. Number of stories?
(� C_ ea`
f. Method of heating? r 1 i !� Fireplaces �i —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? "'y —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
/4C-t� / C-, ( � � as Owner of the subject
property
h r y authorize
t ct on my behalf, in all matter r tive to work authorized by this b 'ding permit application.
Signature of Owner Date �Y/
1 C`.,` �t��,j as Owner/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 pain nd p (ties o ry.
Print Name 1
Signature of Owner/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 _ -
parkin )
#of Parking 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 0 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 Q YES Q
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 NO
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 O NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
1 • I
t
Department use only
- ---- j of Northampton Status of Permit:
dpi king Department Curb CuttDriveway Permit
2 Main Street Sewer/Septic Availability
'Room 100 Water/Well Availability
No
rthi mpton, MA 01060 Two Sets of Structural Plans
phone 413J587- 240 Fax 413-587-1272 Plot[Site Plans
is ;S 1 Other Specify
APPLICATION-TO C-6N—STRUCT,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
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
quA
�• /� �` �'
Name(Print) Current Mailing Address:
Telephone�6�""'�`��
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 (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) ES` Check Number zo
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissionedlnspector ofBw mgs _-" Date
File #BP-2008-0731
APPLICANT/CONTACT PERSON Harlow Builders
ADDRESS/PHONE 336 COLES MEADOW RD NORTHAMPTON (413) 586-0465
PROPERTY LOCATION COLES MEADOW RD
MAP 03 PARCEL 021 001 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 1033- 056 -
Tvpeof Construction• REMOVE WALL&CONVERT BEDROOM INTO DINING RM-S6iol<( C6 D�U jTM-S
New Construction IM;,tST 13f INSTALL,60 F6 t2 (iV EDiTlor) ttIASS %uV;1 C006 1/2, fAlioIL,=J
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 052460
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF013MATION 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-2008-0731
pis#: COMMONWEALTH OF MASSACHUSETTS
v k_ 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-2008-0731
Project# JS-2008-001146
list. Cost: 52000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Harlow Builders 052460
Lot Size(sq. ft.): 81021.60 Owner: KEARNEY MARCI&BILL HUNT
Zoning: RR Applicant: Harlow Builders
AT. 470 COLES MEADOW RD
Applicant Address: Phone: Insurance:
336 COLES MEADOW RD 5
Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:212912008 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE WALL & CONVERT BEDROOM INTO
DINING RM, SMOLE&CO DET MUST BE INSTALLED PER 6TH EDITION 1& 2 FAMILY BLDG
CODE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Lispector 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:
f8q�loq -05-0-
212 et,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo