32C-241 (3) 118 HAWLEY ST BP-2017-1340
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32C-241 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2017-1340
Project# JS-2017-002223
Est.Cost: $5000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
use croup: Homeowner as Contractor_
Lot Size(sq.ft.): 7797.24 Owner: GRAVER JASON
Zoning: URC(100)/ Applicant GRAVER JASON
AT: 118 HAWLEY ST
Applicant Address: Phone: Insurance:
118 HAWLEY ST (413)320-6427 0
NORTHAMPTONMA01060 ISSUED ON:5/22/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF - 13 SQ
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 5/22/2017 0:00:00 $40.00
212 Main Street, Phone(413)587-1240.Fax: (413)587-1272
Louis Hasbrouck--Building Commissioner
-- i
_.. e ,Oefsilbnent use ugly
o City of Northampton Status of Pen 4 1/
tT Building Department Curb GuVDdvew+Ky Pefmd
212 Main Street SewertSepticAvalI ,4ity 'r
�. > i Room 100 Wa lltMe&IAvellabi y fw;
Northampton, MA 01060 Two Sets of Structural Flans 3w phone 413-587-1240 Fax 413-587-1272 PIoUSite Plati r.`.
Meg SPS ,
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION jp.- (1-13 CIO
1.1 Property Address'. / l /
This section to completedbe by office//0 N4✓r7 Sf POP 3C2`
. Lot // Unit
N �/ I Zone Overlay District
Gri ;Arde^ /11t
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
6,14/t/— /
/rr.IW l�'MJfr SAmt A/ cpve
Name(Pnnt) Current Mailing Address'.
r" Telephone c/
Signatu : r il. yam! - yol7
2.2 Authorized Anent:
.$4A.r t✓ Fbore
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 SOd0. 00 (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 C�
6. Total=(1 +2+3+4+5) "y ('600 Check Number (o 8� / 3
This Section For Official Use Only
Building Permit Numbe Date
Issued q
Signature'. .% 16
. —rY O. —�%
Building Commissioner/Inspector of Buildings Oate
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 rued in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L,...._. _.
Rear _._.
Building Height
Bldg.Square Footage °h
Open Space Footage 9
(Lot area minus bldg&paved _.
parkingl
#ur Narking S. es
Fill:
(volume&Incation) _. ._... _ .. .
A. Has a Special Permit/Variance/Fin i ever been issued for/on the site?
NO 0 DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW 0_ YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,ex tion,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YEF O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aoolicable)
New House n Addition ❑ Replacement Windows AHeration(s) n Roofing 171
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs ❑] Decks CI Siding❑I Other
Brief Description of Proposed
Work. Emo.]t - 4,hke /) Ss i?) of elykS SAVel
Alteration of existing bedroom Yes No Adding new bedroomYes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea.If New house and or addition to existing houeina.complete the foflowino-:
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. r' ensions
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 of wetlands? Yes No. Is construction within 100 yr. floodplain_Yes No
j. Depth of basement • 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 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, TdSOf Ave .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
1.11.1
T
I. ,/45N �`/(der 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.
r-7/50/1 61-41/fir
Print Name /
r AO if (2j
Signature o •wner/Agent / Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
B.RiWaterad Home Improvement Contractor: Not Applicable 0
Company Name Registration Number
Address Expiration Date
Telephone
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 0 No
11.- Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 1083.5.1.
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-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 he
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 Zoni ws and State of Massachusetts General Laws Annotated.
Homeowner Signature
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: 7/f //✓fy ,S7 / S014s01
The debris will be transported by: 4%94 Tgc(.my
The debris will be received by: (2/5, etc/J
,
Building permit number:
Name of Permit Applicant R;en l/""'r
5/11/7
Date Signatu of Permit Applicant
The Commonwealth of Massachusetts
nH`;� •
Department of Industrial Accidents
Vat
I. Office of Investigations
a+ . 1 Congress Street,Suite 100
t� Boston,MA 01114.2017
www.mass.govldia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizationllndividual):
Address:
City/State/Zip: Phone#: _
Are you an employer?Check the appropriate box: Type of project(required):
I.® 1 am a employer with 4. 0 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction
listed on the attached sheet. 7. Remodeling
2.0 I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g. 0 Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp. insurance.-
9. ®Building addition
required.] 5. ® We are a corporation and its 10.0 Electrical repairs or additions
3. I am a homeowner doing all work' officers have exercised their 110 Plumbing repairs or additions
Myself No workerscam right of exemption per MCL
[ P I -Roof repairs
insurance required.]' c.151 I(4),and we have no
employees. [No workers' 3.0 Other _ _
comp.insurance required.]
*Any applicant that checks box el must also fill out the.section below showing their workers'compensation policy information.
'Homeowners who submit his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing 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
1 am art employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy b or Self-ins, Lic. d: Expiration Date:
Job Site Address: City/State/Zip:
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 ofa
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the in and penalties of perjury that the information provided above is true and correct.
Signature: Date: rtr4 2
Phone 5: 1/43• Yda' 6ya2
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
T Massachusetts s` ej
t c
•m ftDEPARTMENT OF BUILDING INSPECTIONS ,x,
212 Main Street • Municipal Building o^
•'�" �' Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Bulking Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her I
construction supervisor. 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
• 1 : • 1 1- • 1 • : 1• _ I . 1 • 1 iiy • 1
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
censpecte .
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 DFI AY the project until such time as the proper permits
and inspections are made
/// ��^,,,///
ner/r lent✓si understand the above.
(Home owner/resident's sig lure req ting exemption)
I will call to schedule all required uilding in ections necessary for the building permit issued to me.
Date r/r7i ) ,/
Address of work location A//f/ �/fiet
/(/ 5&
044(8/9b4 / 07060