24A-119 (2) 26 CALVIN TERR BP-2005-0384
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24A- 119 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-2005-0384
Project# IS-2005-0513
Est. Cost: $600.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 8450.64 Owner: THIRKIELD ALISON L C
toning URA Applicant. THIRKIELD ALISON L C
AT. 26 CALVIN TERR
Applicant Address: Phone: Insurance:
26 CALVIN TERR
NORTHAMPTON MAO 1060 ISSUED ON:10/4/04 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF
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 Sisnature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 10/4/04 0:00:00 3387 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
r w C i y of Nortf arn,lon
Iding Department
12 Main Street
-0 , - rt "CC04 Room 1.00 a
0
North mpton; MA 01060 :5 s oY a sem .
,3-58 -1240 Fax 413-587-1272
n;.(1
L ...---*PPLfCAT10N TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1--SITE INFORMATION
1.1 Property Address:
This section tobe completed by office
llf�
iElie Sf.D�stnct CB D�stncti .
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Cur re t Mailing Adm
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 permit applicant
1. Building J (a)Building Permit Fee
2. Electrical �Q ,(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'Sectiori For Official`Use Only
D�
'.Date
Building Permit Number.` Issued:
Signature: r
i
Buildings Commissioner/Inspectorof Buildings Date
4
Section 4. ZONING All Informati6h 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 I I
Setbacks Front { €
Side L: R? Ll R:
Rear
Building Height —'
Bldg.Square Footage { r % --
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?
N0 0 DONT KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I Pageand/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0
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 0 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
w
IF YES, describe size, type and location: II
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 0 , NO 0
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)'
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[CI) Other[dj
Brief Descrition of Proposed ,
Work: c '
Alteration of existing bedroom Yes No Addi new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
=, .F-,. .k •. ^� "-3' "' ..a-. '-"w r-:- -x r- .,1x u�-�.�aarb•.c-+.� rzr -„' ;
sa If I�Teinf hoiase�andor�add#�a�fo ex�s#�ng housing omD eouv�nq:
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 CitySewer 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
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
Date
Signature of Owner/Agent
t
r `
SECTION 8-CONSTRUCTION SE YtCES t
8.1 Licensed Construction Supervisor: Not Applicable [I
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
Rea sere o e�ntp.a�rem n h t a�nr2 �' v- 'N: Not Applicable 0
Company Name Registratiof-Nu-m6er
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M 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...... 0
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 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 shalt 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 Schussetts General Laws Annotated.
Homeowner Signature
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F (riff Pf �'TarflIaliiptolt —
gl f �Rta�aRc[lnsrtla' _
w DEPARTMEI,1T OP BUILDING INSPPCT701.'S
212 Alain Strect ' 2vMunicipal Building
I Northampton, A1ass- OIOGO
j
WOR-10:R'S COIQ'ENSATION GNSUIZ CE AI'FMA. rIT
I �
(ii ccnsxJperml ttcc)
%Vith a principal place of business/residence at: ---- -
(phoney')
(sa ty/ atriap)
do hereby certify, under dic.pp_ins and penalties of peflury, :hat
( ) I am an employer providing the rollowine workcr�s cocnocnsado;: cove agc nor Illy
etuplovecs worlDiig on tilis job:
(Insure CoMrzn-, (Polis:Nt`�r) �:•plration D21`)
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( ) I am a sole proprietor, general contractor or homeowner(Ci:cie one) and have hirea
the contractors listed below wbo have the follo%vino worker's c000ensadon policies:
(iNamc of Contmaor) (InRranc Compan)•/t�Gbc ?-,ruMh—_-) 71r'J Q l�1tC)
I
I
(Name of Contractor) (lnsiraucc Comoam./pOUM, Numcrr) (L'\Di z.6on Date)
I -
i
Mame of Conirano-) (LDsvraac; Compan)-RoUq, Numb`r) (EXpimtion Dau)
(Name of Contractor) a=ranc_- Compzuy/Policy Numbs) (E:pim6on Date).
(nux3 oc5-I c'xa,irnccc-zap•to ax?vd=-iaroc m_:, oo pcviaia.s to..11
O I am'a sole proprietor and have no one woridng for me.
(tom am.a home owner performing all the work myself.
NOTE:plea ix ewuc[h,• .f lc bomwvvcr�.abo c¢xplay pcaoaa to cy-e oo r rc,as work as a d..<�-Z of
nat mae th n ' w err in-ix�1be bomoowner r cmdn oc oa the Qwxic!a z7puten_r1 tbeeo a-c we G==Uy an=al--cd to be
eitplo) -a uncle the--kc"O-+c--*-oa Att(GU452-n 1(5))•:-,pli=6on by a bommava for a lie==or p=mih cry eaid�EL-c
lcp.l—o(ea ea�loyer under thn Woh ola C-c:q- .l Al L
i
!� 1 undcstand Sb.R a oopy of tbia mt.cmr.w my be forMvded to the pcpartmcod of Indutricl Aoci -Ol>'()Irina of ln-+u'+noe for the
coveracst v-1 catioo and that L-i=to sc=m tovcrnse tndcr sod oa 25A of MOL 152 c2n Iad to the i i ioa of aimiasl pco ilwcs
ooau "-of a fine of up to S I}00.00.ndfor i=prj3.00me�t orup to ooc y,end&,_l pcoj.ia is 6c form o(a Stop Wort;ordc Lod a
fim o(S 100.00►ay aVdcA t,,_
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Foc dcp.rt — WY
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Lot R
Sir,pacittt ofLia=ualPc"-r Ucc
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�, DEPARTMENT OF BUILDIJ�G 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 has/her construction sups::-,`s sor. T he state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be,a one or two famivy--
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 f egulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfiIl),
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.
Daze
Address of wor
location cr CCU
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