38-073 (5) 12 BURTS PIT RD BP-2004-0954
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38-073 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-2004-0954
Project# JS-2004-1412
Est.Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Sackrey Construction 040714
Lot Size(sa. ft.): 11412.72 Owner: PUSHKIN MICHAEL A
Zoning:URB Applicant: Sackrey Construction
AT. 12 BURTS PIT RD
Applicant Address: Phone: Insurance:
83 SOUTH MAIN ST (413) 665-9995 O Workers
Compensation
SUNDERLANDMA01375 ISSUED ON.
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 12 X 16 SHED
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 Sienature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 4/9/04 0:00:00 1655 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
} File#BP-2004-0954
APPLICANT/CONTACT PERSON Sackrey Construction
ADDRESS/PHONE 83 SOUTH MAIN ST SUNDERLAND (413)665-9995 Q
PROPERTY LOCATION 12 BURTS PIT RD
MAP 38 PARCEL 073 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 12 X 16 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 040714
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 Commission
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.
City of Northampton k
Building Department
212 Main Street
Room 100
Northampton, MA 01060
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 ' Z 2CO4
'Tlu ' -'W a"` a be completed by office
1.1 Property Address: — � X lf
w az ¥ a
., j�' #,'105
i h �,�k. aa _ ri `tib' b
o l rDt�
2•ane��� � -
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Ehn fi.D119bi r x r„ CB Dl. let
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED-AGENT
2.1 Owner of Record:
Name t) Current M�il��d��
Telephone /
Signatur
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 permit applicant
1. Building 000
,Ia)"Building Permit,Fee
. .
2. Electrical (ti)Estimated_Total Cost of
Construction from 6,.
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fre Protection
6. Total = (1 + 2 + 3 +4 + 5) -Check Numbervd�
This Section For Official MseOnl
Building Permit Number: ✓r Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
A
r
i
II
i
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 Dcpartment
Lot Size
Frontage V "1
Setbacks Front 1.3yf f
r
Side L' R: L:i R• S6 .�
Rear
Building Height 1 r
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
ng)
#of Parking Spaces
Fill:
(volume'&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO — 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 X 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:
t
PT�ONOF�PROPO5ED WORK We peck Ila ' ticale a
•"` z^ <,:m�."�,—..- .�5v.`,."�'t.. ,'`s.,• 3� ,-, ..:,»r-. .>-± .;:a.3�* .:x., .. :: � �;",r.- r...» '>d;�.::r u.x:€'�
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ ,
Or Doors ❑
Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: 1 f1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0• Sheet D
y a ' eW t e -n i additrOW-to exist'inging co"rt' 'tete` te:forMWifit:
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. bimensions
e. Number of stories?
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
k. Will building conform to the Building and Zoning regulations? Yes No .
1. Septic Tank City Sewer Private well City water Supply
SECT11). NER AUTyORlZAT10N 1 O BE COMPLETE I+YHEN
(3WNEFtS gGENT O }CONTRACTOR AFPL E FOR BWLDlNG PERMIT•
1 as Owner of the subject property
hereby authorize to ac; on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1�1 gill
1 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 aenalties of pexJury.
Print e T
Signatur of Owner/Agent pate
t
S1=G74N 8 tONSTRUGT!(2N SERVICES
$ 1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : �/'`7✓(
License Number
Address Exp/ ati Date
Signature Telephone
- e:e : ':, rn m rr;r Caen, Con rac;o.:. 7 Not A/pp�li^!c/a�bhe�/}�D
Company Name Registration Number
Address Expir tion ate
Telephone
SEC7l0N 1Q��WO�RKERS' " MIR N5ATlOIVI INSURANCE<AFFIpA1/IT(M:G:t. c. ]52, § 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....... O No...... ❑
a
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 fann
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 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, Statean4 Loca Zonin" a-,an State of Massachusetts General Laws Annotated.
Homeowner Signature
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DEPARTMEYT df' EmLDrI�G INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S CONITTNSATION 1NSURANC�; A FEDAVgT
with a princip�d plact, of busir,ess/r(�sidenc-- n-,
{SLTC:Ucit _J]rj,
CIO hereby C;e1 L1I}• 1.Il,Itr Chc pr:il2 iii pt il?iil 'S o4 pCt�lll��, I,I1I1i:
X} I an employer providing the foll��v;nt '.�.arr�cr s catnpcns uon cover2�e for my
eltlployces working an ulm jab:
(Lasumncc Camp:m,) dol Date}
Sf�b � (uuv
{ j I acI a sole proprietor, yenPra c-:)rtnc`or ;- horlcot.�xle: ;circle Oct) and •t-:r,.-e hired
the contractors listed beiow `a+', <r: loriters coy pence ion �lcies:
(Na_tbe of Contnctor) �'1St?:�t1 C:, �CIF?t?;:;1-r": O�Ic;j �'�LLGIl�CI} ?:I' :fal0:x Date)
(Name of CantTzctor) (717S�riP.0 Co.-,:-,:)anyPchc-,• Nur b—cr} (E m nll;date)
(Name of Coatnaclo-)
�tn;�:slc� (_os ;�yri'olic� ?v'ItII}ff� (�.�; ;unor ?at•3j
(Name of Cantrnctcr} Date;-
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L %LIl ci stile 131 C)prICLC)i <?IQ hi:VC 110 olli for IIme.
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i0I7::,,lease be nwwa:c
net¢tcce tti-u Shot units in,Ll dt }x f .:...., Z-=:L=cra; k-L•..s zit•r cr st Lhcc c-:t th<
c:nployc5 u_ndcr tar Nmtr', �s ec - _irxi x {C;:-152 ;{S'ti,r: .. ;icr.by a hortcou-tcr fcrr a Lec'.e or F-r:z:i:: .... r e
legal rtxtur of P-0 cunployer under t!:n we ice,'.u>`'L,}Cr_^,.aiiort t.aL j
I unde.zta.nd tbz a copy of Shia ctatci:x_•cuy bo fo,—vc!J to t D-jt Lz o£L-.d .ial 011'5 w of for tax il
—vim-&c vcc.^i c:tioct anis ttut f•ailurc to e-a c co�m_g ut -;s z',"n 25A of MGi.152 cw Icd to the impositiai c,'"r,!-it_I Qet: cs
cow-mina of a rim ofup to S 1.5C{1.CuJ z J t i pr.. Zx.1 of up to cr.-}t ..:.1 civil xnzttiu in t!<Si an c£a Sic',"
w:.d s
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DEPARTMENT OF BUILDIT;G INSPECTIONS
F
INSPECTOR 212 Main Street i Municipal Building 'r>
Northampton,MA 01060 ,
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as leis/her construction sup,.:r,• s,or. 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
I, 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
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