06-001 (7) City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVAT RJE OR ,O FAMILY DWELLING
4
UNIR 17
SECTION 1 SITE INFORMATION
1.1 Properly Address: '#i tech b►office
«1.7c)
•� t—.z1°°f�� xj z�-- .»'`a�' x'S x y ,°"fir .
SECTION 2 PROPERTY OWNERSHIP/AUTHOR?�ED AGENT
2.1 Owner of Record:
Name(Print) Current Mail' Addr
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
=(a)Bwl f Permit Fee'
/4 C)A;,
2. Electrical 0 �c� (0 �Es*ated,1'ota[Cost_,of
Gonstruction fi om I6: "
FMechanical Bu!ldi`ng°Permit Fee
(HVAC)
tion
� .�
6. Total = (1 +2 +3+4 + s) ' /S' k�43 ~Check Number Q —�
This Seciiun For Official,-,Use,Oni
Building Permit Number: 17 Date Issued:
[Signature-
Building Commissioner(Inspector of Buildings Date
r
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot size SC`�,3� (T.
Frontage
Setbacks Front 57 3"7 3c)
Side L: C_ L: R:d b Z()
Rear 110 110 '10
Building Height �V '9? -3S-
Bldg.Square Footage (r j 9.3 3 % 30-3 q.
Open Space Footage U %
(Lot area minus bldg&paved �(�C�7 $- y� ,7(�1 Cl 06
parking) V—.
#of Parking Spaces
Fill: r
(volume&.Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO
4 DONT KNOW YES
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW
YES
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_
No
IF YES, describe size, type and location:
MR ' ✓ a r ✓j °
ECTfO � R > ON�O"FPROPOSED WORK'checkafl a �hcahe, „
� w
n
New House ❑ Addition ❑ Replacement Windows Alteration(s) lal Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ) Other [ ]
Brief Description of Proposed Work: MA:4. f;iN,4Tw4L-- 'cxka Lh-k ;A., 6., - ri �1,,,
Alteration of existing bedroom Yes No Adding new bedroom Yes _/No
Attached Narrative 0 / Renovating unfinished basement Yes No
Plans Attached Roll t9'• Sheet 0
a rfi ew .ous . n oradi=fi n toezistingh uo sin'/." orrp"fie. e. ieforlow n�
a. Use of building : One Family Two Family ✓ Other
b. Number of rooms in each family unit: `4 Number of Bathrooms_
UN's lii � #�
c. Is there a garage attached? kic
d. Proposed Square footage of new construction. 1 l 0 50 F Dimensions
e. Number of stories? 4, ! ,�C C,T<or� :1.
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck 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 14 f(c r
k. Will building conform to the Building and Zoning regulations? V/ Yes No
1. Septic Tank V/ City Sewer Private well City water Supply
SECTIOT7aOWNER AUHORIZATION TQ BE COMPLETED YYH
OWNff�SENTM�CONTRACTOR�pPPL1E5 FOR BUILDCNG PERifIf1T
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
I. 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 Name
Signat a of Owner/Age n Date
I
a
77777M
S�CT)ON 8 CONSTRUCTION:SERVICES
8 1 Licensed Construction Supervisor: Not Applicable
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
RP s Pre bm mpovem'erit ontracto Not Applicable
Company Name Registration Number
Address Expiration Date
Telephone
z.SEGIO .�i.O �IVO�RKERS' 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....... 0 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 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 them
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"homeoNvner"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 Ct��i�LC y � Yt
yr
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6
{:1 174 R(h 116 r 114
m DEPARTMEA"r Of' BUILDING INSPECTIONS
212 Main Street ' Municipal Builcling
Northampton, Mags. 01060
WORKER'S COMTENSATION INSUIZANCE AFFIEDAV1.T
th a principal place of busiresslres dcnc ::
C{0 hel-c!)y ecru-lV. t1Il(1c;- dic p-I MS t11,lt.
am an enaployer prOVldin" the iollov"111L v,ol-kcr's c0119pensaUon covera C Or tit}'
employees working, on gals job:
(InslranG Compa.m') (?c c,Number) --- (FxT-ir-tion Date)
I ac-t a sale proprietor, geaera conirac`or 1?omeow-cer (circle one) and ha.,e hired
the contractors listed beiov. „ho h�.c, the ello :L;: ;oriters c.o pen on pile es:
(r:tttIIC Of CORCI 1CIGr) (II1S� r]C CCIP.r)l-:;1r:'Pchc-y NumL---r) Datc)
(Name of Contractor) -- (drlsJ:Mnce Come::yfPe!ic Namur) (E D ration Date)
— -- — ------
(Name of Contractor) In;•s �siee Co Pol;c i�uis_f r) c, Date)
- (Name of Contractor) — (InsZranc� Commiy Policy Numb�ir) fE;:ni ::ior Date)-
(8IL1G1=d"�IaCQaI
C � � tL[Tl <', solC prUprlf;LC?i <'.I1Q Have t10 Oi1C, '.;Uri;-3iI, t0; il1P-
iIl lloi7?e 0�'%I1C� ti(I:^rIi1IF, �I
f
t`. a Sc
NO TIi:ptcasc be a,va:c Lt!!.�iic tx:rco ;r .o r p1 ,'ir= o::, once a.:-r c'm cr:c;:a r«•,;>: ^..: ..cl... c.
not u,cce than throo uuils in u� et the k yam.,i c ` �.t:.�z r cr r1 lhcao e t nc<cc:y-ral!}'
rl for e Gecrc c.p:r.-.:i:r time
Ic xl status of as
6 a�lo}'or under L:n W«Ya�e Corr-;wr_-,atzon�.cL j
I
I un+3c_'•itaad that a copy of thu ctitc::c=t cuy bo fort tldJ to Ii;n IYtiart.r,:of Inchutrial Ac6&=a-y CiLoo of for tlx
oovcragc vcri =lioa and that Ldurc to ter.rn��rg ut :.cciM 2SA of MGt.152 can lad to dx irnpozitia,cfr ir_1 pct�l:rs
oomitting of a fssr_of up to S 1-500.00 n:1'x i^:nr, r,z c:•±of up to cr, y- r.-.i c v l rsult cs in do fc,In of a stc;`:vnY.O u _rd
f n--of S 100.00 1 day again:L m:. It
-" Fcr dry;,:utrrtsl u-c only i
- Ycrmit t�Iumlrs _
I '
1OI]at1]rC Of ..I )';{`rJhCCntia!_c, - _ 7-,,�.-
Critly of Wart4amptan L
� � �Iasaact�usetts
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/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 backfill),
sonotube holes(before pour), a rough building inspection (before work is
concealed), insulation inspection (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 }}
understand the above.
(Home owner/ s ent's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date 3h 7�� 1
Address of work
location 670 g413(A)44(<
File#BP-2004-0877
APPLICANT/CONTACT PERSON FENTON THOMAS J
ADDRESSIPHONE 670 HAYDENVILLE RD LEEDS (413)584-8496 Q
PROPERTY LOCATION 670 HAYDENVILLE RD
MAP 06 PARCEL 001 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid IX2 C-1
Typeof Construction: REMOVE EXISTING PORCH&REPLACE W/10 X 17 MUDROOM/OFFICE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION PRESENTED:
Approved 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 C ssion
00
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.
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670 HAYDENVILLE RD BP-2004-0877
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 06-001 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-2004-0877
Project# JS-2004-1313
Est. Cost: $15000.00
Fee: $85.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq^ft.): 612889.20 Owner: FENTON THOMAS J
Zoning: SR Applicant: FENTOly ')''HOMAS 3
AT: 670 HAYDENVILLE RD
Applicant Address: Phone: Insurance:
670 HAYDENVILLE RD (413) 584-8496 0
LEEDSMA01053 ISSUED ON.3123104 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE EXISTING PORCH & REPLACE W/10 X 17
MUDROOM/OFFICE
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: `
1,�,t b'�0��✓// Rough Frame:K I -0'z
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation: e7/<
l• $• Q �YU`
Final: Smoke: Final: Ok
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIO
Certificate of Occu anc Si nature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 3/23/04 0:00:00 1850 $85.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo