17A-196 (5) Jan 2e 06 11 : 55a
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DEPARTMENT OF 13UILDrI\C INSPECTIONS -
212 Maio Strcet Municipal Building
Northampton, Mass. 01060
wor CE,it's COIFfPENSA'nON GgSURAJNa Al MI ANTIT
{liCCnscdperrnit ec)
�vidb a plincipaJ place ofbtlsiness/residencc at:
(phoney'}
(str>wt/ritylstatdzip)
do hereby certify, under the.pains and penalties of perjufy., dmi
( ) I am an employer providi.11g the following,workers coinDens-nijop, cove a-c for my
e-luplovecs toning on tills job_
(Insu r-ta=Comp m) (Polirr Number) - (r xpiration Dar=)
( ) I am a sole proprietor, general contractor or homeowner(ci(cie one) and have hired
the eonuaclors listed below rwbo have the following worker's compensation policies:
(Name of CommC.,or) (Insvrant:Corttpany/Palle;.arum.:f) (i-X)IrJtl^n Date)
(Name of Contractor) (llls-dMcz- ComDanwPokv Xcunty) (Exxi raiioa Date)
(N me of Coamacior) (Insurance C omT=)-/PaU:q-N=bcr) (Expirvon Dare)
i
`amc of Contractor) (Insuranct Compmy/Policy i•(umba.-r) (E.rpirarioa Darn).
a
(aoa[b�ddiCOCaI s5rd,ir4romvtr to'vWh�iafam�oo putaitw>6 to.11 000znt•.o:•t) i
8
( ) I
am'a sole proprietor and have no one woriciag for me. l
( ) I am..a home owner performing all the work myself.
NOTE:pl=.+c bt nwyc tlk-W-bomoovrom ubo aaploy pawat to da - nCr cry t ao c rgair work oa.d—u-&of
oot mac III-=._,tJbY t•.�j-io1w6idi the bomooww raido or/oo the potto6;VV a co-rl tbm= `t o%%C-m• y ooer-daod to be
^T1-/�'"-00 the^K =}Qm=P=% o*�(GLI S%=1(5)�r.MUcLdoo by R bomcow oar(cr L 6ccr-x-a pamn m--y C idcooc rbe
legal rs of as acgroy-r ttoder doe W-Iiues Coaapeoa tioQ A,,L
I ttodtv++aod dW a copy of thin aataoa.an maybe forone,rl.d to tbo oepenm w or -.J As Ao&o(Goe er Iraur. rot%6
covr;t•age vaificatto*AM th:t L-irtte to Amuc 100val4v twdar aoaioo 25A of MOL 132 an Sad to gybe tmpozd.aa o(awroal pco+ruo
000ssr�ora floe orup to 51,}00.00 rwk.aa{viaoam=*Cup to ooc ye end coil p.td io c!a ram of a Stop Work Ordrr end e
fim of S 100.00 a day apiva me
dcp�—.:,1 tree only
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map" lAt
Jan 26 06 11 :55a
P. 6
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DEPARTMENT OF BUILDIXG INSPECTIONS
INSPECTOR 212 Main Street ♦ Municipal Building
Northampton,MA 41060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as ],,is/her 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
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 supervisor,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 backf111),
sonotube holes(before pour), a routih building inspzection(before work is
concealed),insulation inmecti n (if required) and a final 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 occupancy
until the work can 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 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
L (b. a� 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
Jan 26 06 11 :55a
p. 4
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Cons ctlon Supervisor: Not Applicable ❑
Name of tic nse Holder
License Number
Address Expiration Date
Signature Telephone
8 etltislSrailtN' eiiiti6ilo w►iiti9r onfifbti?fl '~` ,- "' -' ;?
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152, 25C(l3))
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...... ❑
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 08.3.5.1.
IDet,Ntlon of Hor_egolYner: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 be/she;hail be
rgsoonsible for all such work gerforwed under the building perm,
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)ofthe Massachusetts General laws Annotated,you way 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 Slgnature L'fl,(, " .
Jan 26 '06 11 :55a
P. 3
PEMON 5-DESCRIPTION OF PROPOSED WORK(check Adl applicable)
Now House [3 Addition ❑ Replacement Windows Alteration(s) D Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [a Decks (Q Siding(01 Other far,,
Brief Des ptlon of Propo ed
Work: d0-cc-c- 2a —
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
i,l�>'t�iw�hoiir�e'�,`� Y� d Iota'� zis»rttt` >� i�ttio�,�g:
a. Use of building:One Famiy 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
a. Number of stories?
L Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Messcheck Energy Compliance form attached?
h. Type of construction
I. Is construction within 100 fl.of wetlands? Yes No. is construction within 900 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject
property
hereby authorize
to giybelall,in tters relative to work authorized by this building permit application.
Signature of Owner Date
i,
LA IV 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 pains and penalties of perjury.
Print NarAp
Signature of Owner/Agent Date
Jan 2E 06 11 : 54a p. 2
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
------- -----------
Frontae 7-1
Setbacks Front
Side L: --i R: • .; R:
Rear
Building Height
0
Bldg.Square Footage r X
Open Space Footage ----7 -------
(Lot area minus bldg&paved L. L—J
wkinst)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a S ecial Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW 0 YES 0
IF YES, date issued:
_-- .... I
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON7 KNOW 0 YES 0
IF YES: enter Book Pagel' and/or Document#:
B. Does the site contain a brook, body of water or wetlands? NO (3-1"DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 0 Obtained Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES,describe size,type and location:
D. Are there any proposed changes to or additions of signs intended for the property 7 YES 0 NO Qr
IF YES,describe size, type and location:
E. Will the construction activity disturb(clearing,grading,ex atlon,or filling)over 1 acre or is it part of a common plan
that will disturb over I acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Jan 26. 06 11 :54a
P. 1
City of Northamptonn • ,-' ►
Building Departments
212 Main Street '`
Room 100 °
Northampton, MA 01060 " m
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
. Tfi 3&-vgt1°,tq•.t>s•cork+pleLed by ofNce
1.1 Property Address:
jVl Lot Unit
Tone .pyerlay Disfrict
.F., !St-DlsMct CB.Distrlct
SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.11 Owner of Record: /S� /Ud, �yj"v-/0z x S y
'?d L �_� / Z- jj��Ti�.v� s�L,,,,e z.,u- tiff D/U Z
Name(Print) Current Mailing Addre s:
Telephone
-tom
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
3ECTI2N 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by rmit 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) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissionerftspector of Buildings Date
151 NORTH MAPLE ST BP-2006-0751
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A- 196 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0751
Proiect# JS-2006-1152
Est.Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 9539.64 Owner: BERTRAND ALAN L&CAROL R
Zoning:U_RB Applicant: BERTRAND ALAN L & CAROL R
AT. 151 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
151 NORTH MAPLE ST (413) 584-7156 ()
FLORENCEMA01062 ISSUED ON:112612006 0:00:00
TO PERFORM THE FOLLOWING WORK:WOODSTOVE
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 1/26/2006 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo