23D-015 (5) MEW BP-2004-1176
GIS#: COMMONWEALTH OF MASSACHUSETTS
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-2004-1176
Project# JS-2004-1778
Est. Cost: $4500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Jeffrey Cranston 101176
Lot Size(sq. ft.): 21780.00 Owner: BERGMAN JOY B
Zoning:URB Applicant: Jeffrey Cranston
AT: 560 ELM ST
Applicant Address: Phone: Insurance:
P 0 Box 307 (413) 268-3504
WILLIAMSBURGMA01096 ISSUED ON:5/24/04 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 5/24/04 0:00:00 1058 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
r
Department use only
_City of Northampton Status of Permit
B ing Department Curb Cut/Driveway Permit
`"J 1, 2 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
M AY ' 0 20C4Nor!f�hampton, MA 01060 Two Sets of Structural Plans
`_ phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
i Other Specify
APPLIATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
j L ., Map Lot Unit
P Zone Overlay District
Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Jo Li �,. / -x15
Name(Pr Current Maili�gAddress: C
y\1�1ettiress:0,,.�°L o Co A
• Telephone
Signafure `S B?—0 3. o
2.2 Authorized Agennt:_-
ri 12) b/i C(- A.,/-4e144-;
Nam rin Current Mailing Address:
Si e Telephone
SE ON 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) VCZo ,. Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
1
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
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?7
NO DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO X DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO /'< DON'T 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:
r _
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) -
I
New House 0 Addition 0 Replacement Windows Alteration(s) 0 Roofing 0
Or Doors
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: 1„k, LL LA-c_eI c.... - l--).w
Alteration of existing bedroom Yes / No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll D. Sheet 0
615 fale oustrand `or aaditt;onyto ex,isfingdit usink; bnip i e,following:
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 Nc
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
ja rt2�
I, ,),/ � (( \�� , as Owner of the subject property
hereby authorize c1 to act or
my behalf, mall matters relative to work authorized by this building permit application.
/L-7- („„,y
Signature of 0 der Date
I, 3Tek- ,
as Owner/Authorized Agent
hereby decl e that the statements 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.
.� o C2
Print Na
Sig wner/Agent Date
SECTION'S CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
C Y �F ,: _ Not Applicable LL�Y_• Rr�mm•r:.vemen 1 �n rac#o:-:� ;
Company Name 1 Registration Number
6DX 30 ( 6`.2s-O
Address4
Expiration Date
(41 �.,ail/'1 � Y 'L)/0 76 Telephon tit) )
SECTION 10 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 0 No 0
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
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n �"% DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building • '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE A:1,'l4'U)AVIT
1, ' "TAT C_ &--- ----- __
(Iiccns_Jpermittc,)
with a principal place of business/residence at:
06.- R4z 3�.) __ V4���w-S— 1l" S.1)U1.12._(phone=([/LJ/J �— "7/�,(st'rccticit , -ta^.te/zip) ` ``�`
do hereby certify, under the pains and penalties of perjury, that:
( a.m an employer providing the following worker's compensation coverage for my •
employees working on this job:
ilti %.5. ..._..
- � "
Company) (Policy Num ber) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensator policies:
•
(Name of Contractor) (lnsurancc Company/"Policy Number) (Expiration Date)
(Name of Contractor) -- (insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Corp nyrPolic-y Ntunlr r) (Exi. rauoa Date)
(Name of Contractor) gasurance ComoanylPolicy Numbs) (Expi znion Date)
(attach ad!i$ac,al t cet ifrx-cne^ :n i;_...:.;.:::7—x uion,:..._inin;; ell o:crr_....-.•)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the :':o... myself.
NOTE:plc.ae be aware the While hanco..sr_ra wires ctiploy;r._sc-.to do alastenance,ec:s,:Gim Cr It-pair".'';:;•''e 4..e11i.7"Z cf
not mete than throe units in v.-Lich:he l'.enc outrs rcie...or oc e:x.v:_eis apputc:lard thereto eze not Eczrtally c(c:Ic:::t :a be
employ=under the work? ccir:' -:.::aticn Act(GLI52,ea I(5)),a,:;li=Sian by a homeowner far a liecr:x cr pYa:t::: - ...kocc the
Legal etahu of cn ecesployor under tho Worker's Co. >r..,ation!.es...
I tusderttand that a copy of this ttatcizet may bo fotv.•nrdal to tbo IYtiostascnt of Industrial MiLmta'Oilioo of I:.%urenoe for lb.
coverage vaifrcation and that(idiom to r!o re covorago urd.::xc.ien 25A of 1.1GL 151 can lad to the imposition of criminal penalties
cbmisting of a fine of up to 51.500.00 and'cr ir::}ri:..rrnc:.it of up to cm.:rer r.r.-1 civil penalties in the form of a Stc'Work O i and a
. Lra of S l 00.00 day t::-imt rm. . •
For dciurtrmYal uao only
i Pcrmii Number _____
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'� "4 ' DEPARTMENT OF BUILDING INSPECTIONS _ �= /;
INSPECTOR 212 Main Street • Municipal Building 7`o
Northampton,MA 01060 .
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sups .' sor. 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)t
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