23B-016 (4) 14 HATFIELD ST COMMONWEALTH OF MASSACHUSETTS BP-2021-1762
Map:Block:Lot:23B-016-
001 CITY OF NORTHAMPTON
Permit: Addition
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2021-1762 PERMISSION IS HEREBY GRANTED TO:
Project# Contractor: License:
Est.Cost: $8000 LOUIS MONTGOMERY 013471
Const.Class: Exp.Date: 1 1/19/2021
Use Group: Owner: PREMO, DAVID A. &CLAIRE A.
Lot Size (sq.ft.)
Zoning: 01 Applicant: LOUIS MONTGOMERY
Applicant Address Phone: Insurance:
PO BOX 951 4135220160
WILLIAMSBURG, MA 01096
TO PERFORM THE FOLLOWING WORK: ISSUED ON:08/20/2021
ADD 12X24 LEANTO ADDITION TO SHED
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.
Signature:
• • y9 Tit •
II
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
z-oK -
! Departmemt use only
City of Northampto 14
n tus of Permit:
Building Depa'rtme�it -11�_C 1'1733rweway Permit
212 Main $'treet' QUG S'e- /Sep c Availability
Room 100 2 Q ,, Wat r/We//( Availability
Northampton, MAC 60 �21 Tw Sets/of Structural Plans
phone 413-587-1240 Fax 416 /� PI t/Site4Pians
�� -IihroN rvsps„,-, , her S/ecify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE -DEMOL1SH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map e:;?3/ Lot 0(0 Unit
/Z /his T�:.1/G/' -C.
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: l II
a- � S1 `ve1 L �n
Name(Print) Current Mailing Address:
t7) . S*1 --7 -7 `17
{ t� �r�' o Telephone
s/ Signature
2.2 Authorized Agent:
Zr.,.i.s /l7aw 742004-e.r7 /71!2_7 G✓ /-Nl?7.k/?02 /--). 0 - or- 5'S/ Li////..,s. 1- /' / �i°C.P
Name(Print) / Current Mailing Address:
? ' y/� -- 5'2z -- d/40 o
Signal Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building Q%��U (a) Building Permit Fee
2. Electrical ) / (b) Estimated Total Cost of
N(A Construction from (6)
3. Plumbing �� Building Permit Fee '
4. Mechanical (HVAC)
5. Fire Protection i /7/4- p
6. Total=(1 +2+3+4+5) F_f C� ei C) Check Number lc 1"f
r Official Use Only
,�/,� I 1 � Z.
his Section Fo Date
Building Permit Number. be
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information •
Existing Proposed Required by'7oning
This column to be filled in by
Building Department
Lot Size 1 L_ I
Frontage II
Setbacks Front I
Side L:�s R:� L:I . { R: i
1 I i -i
R �—Rear I
Building Height
Bldg. Square Footage I I % ,r--t ` I I I
---. Open Space Footage
(Lot area minus bldg&paved i G i
parking)
#of Parking Spaces I f
Fill: I — — — - I i
(volume&Location)
9 I ' -
'
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I ! Page j and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: i1 30" >e 6 0`ff f1Acr-ler I'd ACCY %d/7 B(1/1/( 9
D. Are there any proposed changes to or additions of signs intended for the property? YES I NO 1,3
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all.applicable):
New House ❑ Addition Replacement Windows Alteration(s) n Roofing n
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks (0 Siding[El] Other[I]
Brief Description of Proposed
Work:4(k/ /2ite, Y'1'Enfs%PP) ,54.ep/A.(d.7tDA- #4' .STcvt-4f€
Alteration of existing bedroom Yes No Adding new bedroom Yes , No
Attached Narrative Renovating unfinished basement Yes >G No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing complete`the followlncj:
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 CO RACTOR APPLIES FOR BUILDING PERMIT
I, �/T�' �'✓H , as Owner of the subject
property
hereby authorize I ,e'� i✓ I"ir T�hp�12'1
to act on my be 111 'n all matters relative to work authorized by this building permit application.
?(
Signature of O er Date I
I, GdG i S /27c /y1-4,0a-.^.y PA? 2 ✓ j^�Tz1i%-��<<% S , as Owner/Authorized
Agent hereby declare that the statetents 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.
Ld v/.s G"j0f*%lod,a/y
Print Name
0- /- Z
Signature Of Owner/Agent Date
•
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SECTION 8 CONSTRUCTION.SERVICES',
8.1 Licensed Construction Supervisor: t'n.k j W Not Applicable ❑
Name of License Holder: /O✓/- ✓ /17d.•r Pad
License Number
�3 q Pit c.'4%/f,/l /'q/ ictf 7/i>.b+x /5-"17 ,4l v/d C� ! 3 `Z
Address Expiration Date
- /s SZ Z _ U/!o O
/1//,/Z/
Signature Telephone
9.Registered Home Improvement Contractor i; + Not Applicable ❑
Company Name Registration Number
/2 a- /PS)e- y'S/ Gv/ /7/ ,4-7s /'/.�. �7�! v/o44 /73 I /
Address Expiration Date
Telephone,C22 — U/4 b 3/ L 1/ 3
SECTION 10-1NORKERS'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
11. Home Owner-Exemption
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
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:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. n I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
listed on the attached sheet. 7. ❑ Remodeling
2.CI I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
p ty• 9. X Building addition
[No workers' comp. insurance comp. insurance.
required.]
5.tgl We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11.❑ Plumbing repairs or additions
3.CI I am a homeowner doing all work
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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. #: 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 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.
Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: B//
Phone#: /5 - JlZ Z - O/G O
—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#:
City of Northampton _
'
ff( . Massachusetts J F *
Ar, DEPARTMENT OF BUILDING INSPECTIONS ¢ ,
212 Main Street • Municipal Building
Northampton, MA 01060 r`Nfy^a;jl1`�
INSPECTOR
Louis Hasbrouck Chuck Miller
Building 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
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
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
• -NOTE-
' THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS NOT
TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED.
BUILDING LOCATION ACCURACY IS NOT GUARANTEED.
CURRENT SNOW COVER NEGATES THE ABILITY TO ASCERTAIN
ENCROACHMENTS UNDER SAID SNOW.
75.50'
got /(UiIdI) t ?
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700
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I z7 I BOOK 12062, PAGE 40
v,I I PLAN BK. 111, PG. 23
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HATFIELD STREET
TO:
FIRST AMERICAN TITLE INSURANCE COMPANY
TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF
I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING
MONUMENTATION ALL VISIBLE EASEMENTS. ENCROACHMENTS AND BUILDINGS ARE LOCATED ON
THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES,
EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN
A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR
COMMUNITY #250167
—NOTE—
SURVEYOR: T. _1 THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY
r AND DOES NOT CONSTITUTE A PROPERTY SURVEY
ZN ov ,t4s —MORTGAGE LOAN INSPECTION PLAT—
NORTHAMPTON, MASSACHUSETTS
rANDE.ALL PREPARED FOR
r3 ERz y DAVID A. & CLAIRE A. PREMO
\1 say,, SCALE: 1"=3O' FEBRUARY 9, 2021
suRVE/ HAROLD L. EATON AND ASSOCIATES, INC.
REGISTERED PROFESSIONAL LAND SURVEYORS
235 RUSSELL STREET — HADLEY — MASSACHUSETTS
•
The City of Northampton
Building Department
,y �� "��, 212 Main Street
��QRdt£p J1111F.'1'`'1
Northampton, Massachusetts 01060
Phone (4I3) 587-1240
Fax (413) 587-1272
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVAT ION PROJECTS)
In accordance with the provisions of MGL c40, 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, s150A.
The debris will be disposed of in: jet v�/C
Location of Facility -,o at/7 S T /'- T d ,r-A-7,4
The debris will be transported by:
Name of Hauler ,D,o ,-(c/f A..4.t-r0
Signature of Applicant: (---"c"' Date: 8`/'0%
111111111111111111111111111111111111111111111111111111111
•
The Commonwealth of Massachusetts
�f. Department of Industrial Accidents
1 Congress Street,Suite 100
I<, Boston, MA 02114-2017
www.mass.gov/dia
\ Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applica t Information Please Print Legibly
Name (Business/ anization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the propriate box: Type of project(required):
LEI I am a employer with mployees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnershi and have no employees working far me in 8. ❑Remodeling
any capacity.[No workers'camp.ins ranee required.]
3.1:I I am a homeowner doing all work myse [No workers'comp.insurance require .]* 9. ❑Demolition
10❑Building addition
4.17I I am a homeowner and will be hiring contr. tors to conduct all work on my perry. I will
ensure that all contractors either have worke 'compensation insurance or a sole I I.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the su. contractors listed 96 the attached sheet. 13. Roof repairs
These sub-contractors have employees and have 'rkers'comp.inIurance.
6.El We are a corporation and its officers have exercised ,eir rightdf exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'..mp.jtisurance required.]
*Any applicant that checks box 41 must also fill out the section. ow showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are dojng,11 work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet s'.wing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they m4 provid heir workers'comp.policy number.
I am an employer that is providing worker'compensati• r insurance for my employees. Below is the policy and job site
information. j/
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
/
Job Site Address: City/State/Zip:
Attach a copy of the workers" compensation policy declaration p._e(showing the policy number and expiration date).
Failure to secure coverages required under MGL c. 152,§25A is a c i'1 al violation punishable by a fine up to$1,500.00
and/or one-year imprisonjlent,as well as civil penalties in the form of a.TOP WORK ORDER and a fine of up to$250.00 a
day against the violator/A copy of this statement may be forwarded to th- Office of Investigations of the DIA for insurance
coverage verification./
I do hereby certify under the pains and penalties of perjury that the inform,. 'on provided above is true and correct.
Signature: ate:
Phone#: /
Official, se only. Do not write in this area,to be completed by city or town offci,
Cit or Town: Permit/License#
Issuing Authority(circle one):
'1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspe or 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
.
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