32C-224 (60)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: /4'
f
The debris will be transported by:�
The debris will be received by: l /z
Building permit number:
Name of Permit Applicant
Date �Z3/� Signature of Permit Applicant
INSPECTOR
Louis Hasbrouck
Building Commissioner
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060
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frw{S,S
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Chuck Miller
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
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
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
1, 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
'�'` www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
151—
/State/Ziu: Alo,
Z, Phone #: i'3� .
Are you an employer? Check the appropriate
box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. DI am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.#
required.]
5. ❑ We area corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ,QRemodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
tHo meowners who submit this 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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Job Site Address:
Expiration Date:
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 of a
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 pains and penalties of perjury that the information provided above is truce and correct.
Signature: /� �''" Date: ( 2 2 / Z&
9
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):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not
/Applicable F-
SName of License Holder: !�v
Licesens' a Number
-Addr s Expirat- ion Date
T one
9. Registered Home Improvement Contractor:: _ ', u_... ,' Not Applicable £
Compa ame Registration Number
Address !� Exi�f' atio ate
elephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 162, § 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..Ll.. £ 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 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 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House F-1
Addition ❑
Replacement Windows Alteration(s) Roofing ❑
Or Doors D
Accessory Bldg. ❑
Demolition ❑
New Signs [1:37 Decks [M Siding [O] Other [O]
Brief Desccri tion of Proposed //
4[, �_.
a,Q%ci yct �- t�-�ict 1F��
c✓G�7►'; ,V`/
Work: �tvyll.�
/,�/� L.)nt l l TSU .%�
Alteration of existing bedroom Yes _ L__ o Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement es _ LNo
Plans Attached Roll - Sheet
6a.`If1New house an .-or: "adtl`ition to exfie,66:h"ousing comp[efe the-followmg:
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 City Sewer 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
/
h e'by authorize
o act on my behalf, in all imatters relative to work au or' ed by this building permit application.
z 7f
wner Date
as Owner/Authorized
I,
Agent here y declare th the stat rents 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 Na y
Signature wner/Agent Date
Section 4. ZONING
All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
DONT KNOW 0
Existing
Proposed
Required by Zoning
This column to be filled in by
Building Department
Lot Size
��
1
Pagel_
i
and/or Document #
Frontage
Setbacks Front
Side
Rear--
L:= R:=
L:(__ _! R:_ _
Building Height-�
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
—t} %
# of Parking Spaces
_
Fill:
(volume &Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Or DONT KNOW 0 YES Q
IF YES, date issued: ~�
IF YES: Was the permit recorded at the Registry of Deeds?
NO
Q
DONT KNOW 0
YES Q
IF YES:
enter
Book
1
Pagel_
and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtainedQ Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, txclavigfion, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
Building Department
`�\`��.FsSiy
QL �% 212 Main Street
1� \ :^.
' Room 100
s
\ +
Northampton, MA 01060
4Q F�
phone 413-587-1240 Fax 413-587-1272
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eP M. , ehtl �tse only r ,
3�
Status of Permtt
ht 6 11 a i� wt ra1, rt
ri.
Penni# ak�1 ,
tlt� 1 �tl Y 14 T R
Seyverl5gpticAvaifabl(Ity I h' u
V 1 rv" jy E' 1=i ] 'i k* 3 i 1 1� }S. iI4H✓' i SJ
Water/VkletEA�adaf}ility
, J A. i � Ii 5 , 11 JAS i
Two 4..Ogpti pt'u
Frr{ ru ilr ' 84y.
P[of/SiYe Plans I A i t 1 L� x Y 55 4 +h s g I L
i 01
Other Specify' F Ism � M i rr�� x' � bll � r t :,
PPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
*-7?
SECTION 2.- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
_. ®iipnck L%_" 1l Lc An
Name (Print) Q�-�r� Current Mailing Address:
Telephone
Signa ure
2.2 Authorized Agent:
Name
j
Current Mailing Address:
Telephone
.SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building S a (a) Building Permit Feb
i
2. Electrical (b) Estimated Total Cost of
ov Construction' from*(8)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Q -QrV Check Number
This Section For Official Use Onl
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector'of Buildings Date
File # BP -2015-0345
APPLICANT/CONTACT PERSON C & T CONSTRUCTION
ADDRESS/PHONE 15 Fairway Drive FLORENCE (413) 586-4965
PROPERTY LOCATION 79 HAWLEY ST ecA t St((
MAP 32C PARCEL 224 001 ZONE URC000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid f r.., v
TyDeof Construction: ADD WALL & DOOR AT TOP OF STAIRS
New Construction
Non Structural interior renovations
Addition to Existing-
Accessory Structure
Building Plans Included:
Owner/ Statement or License 062884
I sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
proved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR.
Major Project: Site Plan AND/OR
ZONING BOARD PERMIT REQUIRED UNDER:
Finding
Special Permit
Special Permit With Site Plan
Special Permit With Site Plan
Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW
Septic Approval Board of Health
Water Availability Sewer Availability
Permit from Conservation Commission
Well Water Potability Board of Health
Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demol' ' elay
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.
Re►Lto?S
79 HAWLEY ST BP -2015-0345
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 224 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP -2015-0345
Project # JS -2015-000632
Est. Cost: $2750.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group C & T CONSTRUCTION 062884
Lot Size(sq. ft.): 2395.80 Owner: WANG FAMILY TRUST
Zoning: URC(100) / Applicant. C & T CONSTRUCTION
AT. 79 HAWLEY ST
Applicant Address: Phone: Insurance:
15 Fairway Drive (413) 586-4965
FLORENCEMA01062 ISSUED ON. 9/2412014 0:00:00
TO PERFORM THE FOLLOWING WORK. -ADD WALL & DOOR AT TOP OF STAIRS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W.
Underground: Service:
Rough: Rough:
Final: Final:
Gas: Fire Department
Rough: Oil:
Final: Smoke:
Meter:
House #
Driveway Final:
Building Inspector
Footings:
Foundation:
Rough Frame:
Fireplace/Chimney:
Insulation:
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 9/24/2014 0:00:00 $55.00
212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272
Louis Hasbrouck — Building Commissioner