23D-024 (5) ' '1 BP-2006-0192
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0192
Project# JS-2006-0285
Est.Cost: $6500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Robert Thibodo 118441
Lot Size(sq. ft.): 4007.52 Owner: GRENAT CARMEN
Zoning:URB Applicant: Robert Thibodo
AT: 492 ELM ST
Applicant Address: Phone: Insurance:
P 0 Box 201 (413) 586-0391
NORTHAMPTONMA01061 ISSUED ON:8/22/2005 0:00:00
TO PERFORM THE FOLLOWING WORK STRIP & SHINGLE ROOF
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: Date Paid: Amount:
Building 8/22/2005 0:00:00 $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 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
1.1 Property Address: >> This section to be completed by office
7 �fl� ��� ST• Map Lot .._ _._. Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ea rrn i 6reo '�/9� t/py) W , Nar-iXA-> J IV
Nam nt) n Current Mailing Address:
/( , \o att Telephone (f(f
Signature I �'
2.2 Authorized Agent:
n
'66 , -77-t1 PoJ u 12o, bon Aa1, NDr- ia-i N 0104/
Name(Print) Current Mailing Address:
4l 3 -Sd rl `6,63
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ti
floor 4", (a)Building Permit Fee
1 f6 �p
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) (09)0 i u)6 Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
` h
i
Section 4. ZONING All Informatioh Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size ' ` I i
Frontage I , l
Setbacks Front _ i 1 I
.
Side L: I R:r L: R:i 1
Rear �' 1 ,
Building Height
Bldg.Square Footage i % 1 f I
Open Space Footage r� % —j
(Lot area minus bldg&paved I l ( I I I
parking)
✓_ 3
#of Parking Spaces
Fill: ' 1(volume*Location) `
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Books Page; i and/or Document#: 1
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission? '
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size,type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
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 E. Replacement Windows Alteration(s) Roofing
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [D Siding[IJ] Other[dj
Work:Brief escrip e W1of Proposed"
J etcWS+l 116. roof! Re. 'wadi n eti rim
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
( ew ocls� radar is o4exlstffacl o sinq compTe e ee 1toWtnq:
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 AGENTsOR CONTRACTOR APPLIES.FOR BUiLDING.PERMIT
I, Ccu(VY A/1 01 e)Y1a4 ,as Owner of the subject
property (� .
hereby authorize Q I; L 1 �[ gj 0 if
to a n my behal,int;I matters relative to work authorized by this building permit application.
Signa ure of Owner Date
Toff, Tt t v)oJb ��
I. ,as Owner uthorized
went hereby declare that the statements and information on the foregoing application are true and accurate,to the best of know1ge
and belief.
Signed under the pains and penalties of perjury.
6 ii _6u Nen
Print Name
21 o�
Signature of wner/Agent Dafe
SECTION 8-CONSTRUCTION SERVICES r '
8.1 Licensed Construction Supervisor:� f Not�Applicable
_ Q❑
Name of License Holder: O 1') I Tf 166DO f l 6 J lU r !
License Number
39\ Er,&sf S-1-. Ea01)0411-6N HA o /09,7 2-2 -o�
Address Expiration Date
Signa ure Telephone
e ere me.in en ra o Not Applicable 0
--t.O (g t B o o, po i tv6. N 6 I .��
1 �-f l
Company Name Registration Number
P. o. 69 o I ) ovr -0- -f-o rv, �1A oio(I (0-2-2--D
Address r� / Expiration Date
Telephone 00.3-69 /i?
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
erk
lm e i I
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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O4(itn.HPLO J..
F, E (rii of arf(ianiiptoli
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DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street Municipal Building •
Northampton, Mass. 01060 r''
• WORIC R'S CON PENSATTO.N LNSUTPANCE Al 1W)A\' T
•
•
-- — -- Oicens&permittec)
with a principal place of business/residence at: -
(phonef')
(scr=lcit /sia rizip)
do hereby certify, under the pains and penalties of perjury, i_hai
•
( ) I am an employer providing the following worker's comnensa:ion coverage for my
employees worng on this job:
•
•
(i�sur-mac Cocipzsy) (Policy Nu_ cr) (=:-pirtion Da.c)
•
( ) I am a sole proprietor, general coon-actor or homeowner (cicie one) and have hired
the contractors listed below wbo have the followi.nz worker's comben_ation policies:
• (Nam: O; Cot?tracior) (Insuranc Coinpan-y/Poiic Numbs ) (`r_:-piracon D ttc)
(Name of ConO c1or) (Insuran= Compcny/Poke,' Nunbcr) (%xpirtion Dalc)
(Name of Contractor) (I»_suranc Compaoy/Polic7' Number) (Expirtioo Date)
•
• (Name of Contractor) (insurance Comr,:a,;/Policy Number) lr.:.-pirltion Date) .
(sasu' sddihrod sere ifocaoz._7 to atdud:iaforrydcc pclnini to.11 we-tors) •
( ) I am a sole pFoprietor and have no one woridng for me.
( ) I am home home owner performing all the work myself.
NOTE:plese be ccrarc tfi•• +-JC bomcawacn wbp eaploy pal.om to do e• rw c— ,00 a tens work 02 r d„cJl_o of
not more the ttom-or tmks in adyth the boc000,vo raid=o oo t c p-ou d purico tbecen L:cot Cry.--tly oec d-ni to be
eitpIcy=tine,.the Aa(GL1152y 1(5)),appt;r,r;oo by.bommava fc c lie oc permit rLy c.-idmoc the
Icgsl rt�,.of ea. ploys under tho Wo icdr Com,om.t,ioc I o
I uadersaad tht a copy add.msrmma m.y b.foe•.rvd..d to tb.Dep.nmm¢of lnz!..+srid nsddoots'Otro.of Im++�oco for tb•
covci be vc-if attic= that Etiltae to scutrc'covcrabt tmdc scanon 25 A of MOL 157 can 1cd to the inarpOsaica of eimiarl p•c,,tries
oom.i�rzg of a floc of up to S 1 SOO.00.rtdJor imprisoccennat of up to ooc y-,3r r.od d ail pr.,.F,ict io 6c forest of.Stop Work Ordc.od.
II=of SI00.00 a day spin co
For bepons=�u.e on17
Permit Numbcr
l.(ap." Lot
Sii n,-tturr of Licanstx/Pctsniucc [ste
T ,
O¢ tAMp1. —_,—
_� . ;e .(ri >�r az�l�ttnt turY • z---'`= _/.
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j�Tiassacltasetfs _' {- -
vi 'ra DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building '>a 'Northampton,MA 01060 ,v S �
e'
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 wilding department for the City of Northampton wants any persons)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 z egulations. 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-tome
Date
Address of work
location
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