42-095 (6) r -e
220 GLENDALE RD BP-2004-0821
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map_Block:42-095 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0821
Project# JS-2004-1220
Est. Cost: $1000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 52272.00 Owner: BRESNAHAN WILLIAM M&BLANCHE
Zoning: SR Applicant: BRESNAHAN WILLIAM M & BLANCHE
AT: 220 GLENDALE RD
Applicant Address: Phone: Insurance:
220 GLENDALE RD (413) 586-5473 O
FLORENCEMA01062 ISSUED ON:2/25/04 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 si nature:
Feer e: Receipt No: Date Paid: Check No: Amount:
Building 2/25/04 0:00:00 1620 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
Department use only
City of Northampton status of Permit:
Building Department curb Cut/Driveway Permit -
212 Main Street Sewer/Septic Availability-
Room Room 100 Water/Well Availability
FEB 2 F 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 Address:
R Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
a'/G L /Al% k-D
Name nnt) Current Mailing Address:
L Telephone
Sig ature
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
(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 = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This colurrm to be filled in by
Building Department
Lot Size
Frontage Q /
Setbacks Front 5
Side L: �C� R: L: R:
Rear
Building Height
Bldg. Square Footage l�Gl0 %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding,eveer 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 L/
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 5 DESCRIPTION OF PROPOSED WORK (check all applicable) -
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing .
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ J Siding[ J Other [ ]
Brief Description of Proposed Work: 9fww--E o,-F O✓i5p (�v
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes
Plans Attached Roll O• Sheet❑ No
6a; lf`New ho"usea nd or":addition-to WiK" iRT11FhoUN-1t oml:e"fe MUM
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
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 CONTRACTORAPPLIES FOR BUILDING PERMIT
I,
---- as Owner of the subject property
hereby authorize
my behalf, in all matters relative to work authorized b Y this building permit applicationto ac or.
.
Signature of Owner — —
Date
s Owner/Authorized
I,
hereby declare that the statements and information on the foregoing application are true and accurate to the best of mgyent
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name —
Signatur of Owner/ Date 5`
i
SECTION 8 ;c NSTRUCTIQN SERVICES `.
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Reg�" sie edt�o`m"f1 prouement_Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS' COMPENSATION'INSURANCE AFFIDAVIT(MG.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)fami:ies
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
OSS t 1AHPJ,
tiIL
� ,.> r fo �ia3aacflnarfla -
n cfl DEPARTMENT OP BUILD
r,,,rG INSPECTIONS -
212 ilTain Street ' Municipal 13uilding
Northarnptou,
S. OlOGO
WOPdCER'S COMTENSATION INSURANCE �AV1T
I,
�:ritll a principal �lacc of business/residcnc at:
(SiTL;^t/C7f�;/Siei17-Jp� •- ..— _�---
do hereby cer'ut}, un(Ier tllc pi ns sad penalties of perjury, that:
O I am an emp�oyer providing the followint .vorr;cr`s compensation cover2�=e for
empyees worldrlg on t11is job: Iny
lo
mpaay) _—
(PeLc:Nu.']]bcr) (F--&-pinion Date)
( ) I aci a sole plroprietor, general C-011trctor or homeowner (circle one) and have hired
the contractors luted beiow;, ro
ho h the lllo:y,�� rgorker's Compensasorl polices:
J
L`1J1tnC Of Corttrt for \u1Stt�ilev COli1D;: •,n-
r'1)o(iry Ntunbcr) (Exp:rnticr,Date)
(Name of con trctc�r} (lu"Slrancc CoMaIV/polict• Number) -
(1�.y.r�ration Date)
(Name of Contractor)
(In7Jr trice ComE,an}vr�olicy Nrtrnlf�r) ��
a_x�.;, Late)
(Name of Con�t*gi tor) —- Com , y 1 olicy Ntlm J) —
(r.ttaClt adlitioaYJ mcct if:i (InSllran r-� /7
n•- .�:;{: (Exp-:-:tion Date)
✓� ) ) ittIl i! SAIL l)rUl)I7f CUi' i!I11 hz1ve i10 OI1C i/.�lli
Jt� l <1Ik1 i? home Q)V,r er y r lOr tile.
_ I , I..: perfcrkntn-.
lliy_self.
NO"M:plc:Yc be awa:chc(ncowlrsa N
not there tJt a throo uni.a ir,ui`�+t �•.t!r rc C kCY�>w-sc to c:)� tr-,,- aaCC,ox-e-r•Cioo Cr t-pair�.•••tf:un i d��cl!i:�Cf
!x k x k. .L:a ex oa -
=Ploy=u_ndCr the�yC:i,.Y3 ca. et '�` 'YJt•1r er—r1 thcreto a.•t ext Cm-rally
legal natua of na eaploye<un thn W r.(('L152_-a! S ;.s�.k:a:ion by a hot:)eo%my for a�ca-zc a p-rmi:r r.:n-�.,, c un
6 ( )
. �paralion tet
Wye-9c�f Oa� f th a rtatrn:xt nutya co be forwnrcled to the(yt tzrnt of lodustriJ AtxiLrn:f UJrcw of kr_xuanx for the
romistard of a fine of u to S I Q0�to t!atrc covT°'•ur:�r"c`'i�25A of 1.{GL 152 raa Irk to tlx irnpositiorf ofc 1
me of S 100.00 a da &&:6,0 nv ar K i^ rr xtz)r.of up to Cr.:}`r r:.I civil DCM16cs in do f(-Ain of a Str+4Jcrk(}�-anal a
Y
For(Scputnr ral use only
Permit Ntu IXU,
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municilull Building
INSPECTOR Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction supe:-„icor. 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
spections before the work is concealed, failure to
building department requires these In
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
.7 �, 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