31B-255 (2) 60 STATE ST BP-2004-1101
GIS#: COMMONWEALTH OF MASSACHUSETTS
54D 255 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-2004-1101
Project# JS-2004-1640
Est.Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use croup: James Roberts 117154
Lot Size(sq. ft.): 10890.00 Owner: GROWHOSKI THOMAS M&JOHN M
Zoning.URC Applicant: James Roberts
AT. 60 STATE ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON:5/6/04 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER 1 LAYER
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• Receipt No: Date Paid: Check No: Amount:
Building 5/6/04 0:00:00 2106 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
Department use only
�( of Northampton status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This section to be completed by office
1.1 Property Addres
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
igna e
2 2 Authorized Agent:
Name(P t) Current Mailing Address:
g ture Telephone
ECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (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
6. Total = (i + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: Date
Building Commissioner/Inspector of Buildings
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
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
par kin )
#of Parking Spaces
Fill:
(volume&LocaMon)
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 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:
SECTION- DESCRIPTION OF-PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ) Decks [ ] Siding[ ) Other[ ]
Brief Description of Proposed Work: .
Alteration of existing bedroom Yes No Addin new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll Cl - Sheet
ff feti o�i"u a ndor: iiltion to 71ezistln�hous'i'ng coW61,-e a tM foflowln :
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. Mascheck Energy Compliance form attached?
h. Type of construction
L 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
hereby authorize to act on
my behalf, in all matters rela iv to work authorized by this building permit application.
Signature of Owner Date
I as Owner'Authorized Agent
hereby clare that the statements and information on the foregoing application are true and accurate, to the best of my
knowl ge and belief.
Signed nder the pains and penalties of per' .
Pri t ame
i ature of Owner/Age t Date �"
SECTION 8=RCONSTRUCTION SERVICES
8.1 Licensed Construction Su rvisor: Not Applicable ❑
Name of License Holder
-------- License Number
Address Expiration Date f
Sig a re Telephone
Ref s ere 3orne 'mnrovemC
ent ontracto Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
.SECTIO'N10 '1NORKERS' 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....... ❑ 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"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 fu,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 resu!ting 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
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DEPARTMENT OF EtUILDIT(G INSPECTIONS
212 Main Street ' Municipal Building
NTorthamptor], Mass. 01060
WORKER'S COMI TENSAU0N INSURANCE A: i M kVIT
Le
(Been&Jfrrmittc^) __.--
N:t1111 a princ al place of business/residence at:
—..---•—
do hereby certify, under the pains gild penalties of perjury, that.
O I aman eruployer providing the following % orl:cr'-s colnpcllsation coverage for my
e111plovices working on this job:
(LnszuanG Coctprm) (?eiic;Number) (Expirtien Daze)
( ) I aai a sole proprietor, general C4)n=cl:or or houieowner (Circle one) and have, hired
the contractors listed below;,•ho 1121. the font,, g vqorker�s compensation policies:
,,Name of Contm'-100 (Insumnec Compan f'Toliey Number) (Ex l.ration Date)
(Name of Contretor) (Insurance Companylpoiicr Numtrr) (Fjxpiratio l Date)
(Name of Contractor) J1117umnc-- C0Mi7a0)'P?01icy N=N--r) - Ex�.:r Coy Date)
(Name of ContTictor)
(attadt ad•!itiena!react irt:-- •,- �asuranceCQIDr: ,y/Policy Numbr) (Expi,-,fli70'Date)
all c cw_..a,.•)
I iuTl 21 Ole proprietor and have 110
one i:rhllii 10f ?IIe.
I <1rI1 t? home Off';?1Cr DCI?Ci ITlln all ti)" ,o:'r: iii`15:!1.
NO"fI:plc,,Lc nu a c t±ta:wile 6cctxo�im trr�c--t,lay;x�a to d>tea; t aancr,w-:.n:�m cr mpa'v:%-,n:on,d.%rlli.,ci
not a—tIi n throo u>it3 int:{%,i-.'ch he 11, a, `: •;:� ti rter_r1 thac ac e ttc{Scrrszlly oa ::::':o h
C- ploycs un;er t"twr);.Ys cc _:slim:r (GL
S?sa 1(Sl),npr•t:=:ic:t by a hotncow=for a L-cc:x cc p Ymi::::a;:c. roc tl;c
Ie821 rtatut of an employer under ttte Woc'trls Cor� tion AcL
I uade.•stand thi a copy of this rtatc,=may b,,f(x,nrded to tbo U tiarLtxnt of rndzLstriJ An,-id.tf Olrim of!:Zkw sx for tlx
oovaaSe vof it ciion and that failtttt to
coasisting o :cats:mv:tzr-u'!d,:ccc,iln 25A of?.(GL.152 ran lc--d to the imposition of cr.• Li - p=uW a
f a fssr_'of up to S 1�00.p0 at '.'or ir.:pri xtn c y or up to )w a-d civil pensltics in dc foon of a Ste;,Werk Ord—and a
Lre of 5100.00 it day iLainr�t rrr-
Far&,p=Usrseal uie only
Permit NtunbCr _ ___.-----••_---.I
of I.icr]]:c:JI' [n]ittr......
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DEPARTMENT OF BUILDD,,tG INSPECTIONS
INSPECTOR 212 Main Street • Municirll 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 supe:::i or. The stale 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