Northampton Building Application (1)City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ● Municipal Building
Northampton, MA 01060
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES,
FENCES, GROUND MOUNTED SOLAR, ETC.
1. Building Permit Application signed by legal owner and filled out by owner or authorized agent.
2. One set of plans and specification of proposed work (digital and hard copy).
3. Site Plan with location of proposed structure(s) and setbacks.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker’s Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (new/replacement windows).
8. Home Owner’s License Exemption Form filled out and signed by homeowner (if applicable).
9. Note any Conservation and/or Special Permit requirements (if applicable).
10. Driveway Permit (if applicable).
11. Proof of Water and Sewer entry fees paid (if applicable).
12. Trench Permit - public land by DPW/Private land by Building Dept.
13. Stretch Energy Code – all new construction will require a HERS Rater Affidavit to be submitted with
permit application before issuance of permit.
The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
FOR
MUNICIPALITY
USE
Revised Mar 2011
This Section For Official Use Only
Building Permit Number: _____________________ Date Applied: ______________________________
___________________________________ ____________________________________________ ___________ Building Official (Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address:
____________________________________________
1.1a Is this an accepted street? yes_____ no_____
1.2 Assessors Map & Parcel Numbers
_____________________ ____________________
Map Number Parcel Number
1.3 Zoning Information:
_______________ ___________________
Zoning District Proposed Use
1.4 Property Dimensions:
_____________________ ____________________
Lot Area (sq ft) Frontage (ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40, § 54)
Public Private
1.7 Flood Zone Information:
Zone: ___ Outside Flood Zone?
Check if yes
1.8 Sewage Disposal System:
Municipal On site disposal system
SECTION 2: PROPERTY OWNERSHIP1
2.1 Owner1 of Record:
________________________________________ _________________________________________________
Name (Print) City, State, ZIP
_____________________________________________ _________________ ___________________________________
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2 (check all that apply)
New Construction Existing Building Owner-Occupied Repairs(s) Alteration(s) Addition
Demolition Accessory Bldg. Number of Units_____ Other Specify:________________________
Brief Description of Proposed Work2:_________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ 1. Building Permit Fee: $_______ Indicate how fee is determined:
Standard City/Town Application Fee
Total Project Cost3 (Item 6) x multiplier _______ x _______
2. Other Fees: $_________
List:_________________________________________________
____________________________________________________
Total All Fees: $_______________
Check No. ______Check Amount: _______Cash Amount:______
Paid in Full Outstanding Balance Due:__________
2. Electrical $
3. Plumbing $
4. Mechanical (HVAC) $
5. Mechanical (Fire
Suppression) $
6. Total Project Cost: $
218 Drury Ln. Northampton,MA 01060 book&Page : 3576, 172
residential
x
Myles Powers
218 Drury Ln.
Northampton,MA 01060
413-695-1557 mylespowers1983@gmail.com
x
x pv solar panels
installation of roof mounted pv solar panels- total system size of 13.050Kw- total numberof panels is 45- total amp size is 200A
9,625.68
38,502.72
48,128.40
0
0
0
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
________________________________________________________
Name of CSL Holder
_________________________________________________________
No. and Street
_________________________________________________________
City/Town, State, ZIP
_________________________________________________________
__________________ ______________________________________
Telephone Email address
_____________________ ______________
License Number Expiration Date
List CSL Type (see below) _______________
Type Description
U Unrestricted (Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
D Demolition
5.2 Registered Home Improvement Contractor (HIC)
______________________________________________________________
HIC Company Name or HIC Registrant Name
______________________________________________________________
No. and Street
________________________________________ ____________________
City/Town, State, ZIP Telephone
_____________________ ______________
HIC Registration Number Expiration Date
_______________________________________
Email address
SECTION 6: 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 ………. No ………..
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER’S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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.
______________________________________________________ ______________________
Print Owner’s Name (Electronic Signature) Date
SECTION 7b: OWNER1 OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
_____________________________________________________________ ______________________
Print Owner’s or Authorized Agent’s Name (Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned, provide the information below:
Total floor area (sq. ft.) _________________________ (including garage, finished basement/attics, decks or porch)
Gross living area (sq. ft.) __________________ Habitable room count ______________________
Number of fireplaces______________________ Number of bedrooms _____________________
Number of bathrooms ____________________ Number of half/baths ______________________
Type of heating system ___________________ Number of decks/ porches __________________
Type of cooling system_____________________ Enclosed ______________Open _____________
3. “Total Project Square Footage” may be substituted for “Total Project Cost”
Daniel Rubin
135 Robert Treat Paine Dr.
Taunton, MA 02780
774-320-5539 permitsma@freedomforever.com
CS-111662 02/19/2021
U
Daniel Rubin/Freedom Forever Massachusetts LLC 198080 03/01/2022
permitsma@freedomforever.com135 Robert Treat Paine Dr.
Taunton, MA 02780 774-320-5539
x
Daniel Rubin
Myles Powers 10/07/2020
Daniel Rubin 10/07/2020
CITY OF NORTHAMPTON
SETBACK PLAN
MAP:_______ LOT:________
LOT SIZE:____________
REAR LOT DIMENSION:_____________________________
FRONTAGE_____________________
REAR YARD _____________
SIDE YARD______________ SIDE YARD______________
FRONT SETBACK_______________
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ● Municipal Building
Northampton, MA 01060
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number ________________ is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: ___________________________________________________
The debris will be transported by:
Name of Hauler: ______________________________________________________
Signature of Applicant: __________________________________Date: ___________
135 Robert Treat Paine Dr., Taunton, MA 02780
Freedom Forever Massachusetts LLC
10/07/2020
Daniel Rubin/Freedom Forever Massachusetts LLC
135 Robert Treat Paine Dr.
Taunton, MA 02780 774-320-5539
x 7
pv solar panelsx
Milestone Risk Management & Insurance Services
01/01/2021
218 Drury Ln.Northampton,MA 01060
FRWC113471
774-320-5539
10/07/2020
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ● Municipal Building
Northampton, MA 01060
HOMEOWNERS’ EXEMPTION ELIGIBILITY AFFIDAVIT
I, ________________________________________________________ (insert full legal name), born __________ (insert
month, day, year), hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners’ exemption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a
parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners’ exemption,
does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3.
3. I qualify under the State Building Code’s definition of “homeowner” as defined at 780 CMR 110.R5.1.2:
Person(s) who owns 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 home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for
and will abide by the Massachusetts State Building Code’s requirements for the supervision of the project or work
on my parcel, I am not engaged in construction supervision in connection with any project or work involving
construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any
provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my
parcel, I acknowledge that I am required to and will act as the supervisor for said project or work.
Signed under the pains and penalties of perjury on this _____ day of _______________, 20___.
___________________________________________
(Signature)