23D-116 (2) IVA FEsD1rR11t ; . _`:`.a.G BP-2003-0978
GIS#: COMMONWEALTH OF MASSACHUSETTS
igooximempsweri CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0978
Project# JS-2003-1574
Est. Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 30056.40 Owner: CARRASQUILLO ANGEL&
Zoning:URB Applicant: CARRASOUILLO ANGEL &
AT: 202 FEDERAL ST
Applicant Address: Phone: Insurance:
202 FEDERAL ST
FLORENCEMA01062 ISSUED ON:5/8/03 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 5/8/03 0:00:00 4232 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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City:of Northampton Status ofk ' �aj�r
r Building Department Curb Cut%DA
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------- -212 Main Street Sewer/Septic AvairabiJity
Room 100 a ter7We11'Avai(ability
MAY — 2 FOthampton, MA 01060 Two Sets of SfrUctural P ans
phone 413.587.1240 Fax 413-587.1272 Plot/Site Pla sR �
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OtherSpecify4-464A
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
Map Lot Unit
l ` 6 lc Zone Overlay District
," Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2. wner of Record:
gaifrife1C5ill Z— caml Si •
arne(Print) ( Current Ma ling Address_:_
- ,..04//1(27...telf,---, '` I, ?-6-) -- �, �(3 C�
Telephone
ignature
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
/i. 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 column to be filled in by
Building Department
Lo •r'
Fron .g-
Setbacks ront
Sise 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 Sp cial Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T 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:
SECTION_5- DESCRIPTION OF PROPOSED WORK1check all applicable)
New House ❑ Addition 0 Replacement Windows Alteration(s) 0 Roofing 0
Or Doors)KJ
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Bri escription of Proposed Wo) L A \ (N l `Q )
Alteration of existing bedroom Yes No Adding new bedroom Yes ✓No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6 If N'Mtic`u`s'e' anEl o a tlition to existin` houai ikW omplele" the fi,l'L i rg
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 CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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.
Signature of Owner Date
, as Owner/Authorized Agent
hereby declare 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.
Print Name
2-
Sig ature f Owne Date
SECTION 8 -CONSTRUCTION SERVICES /
8.1 Licensed Construction Supervisor: Not Applicable C�
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Re Ste°edFlm`efmprovementContracto'r' "tea at A 1 Not Applicable 0
Company Name Registration Number
Address Expiration Date
Telephone
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
I 7 ,ome. 0 wner44 +°xemptlon
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.
)k Homeowner Signature �Q�,t - � �
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DEPARTMENT OP BUILDING INSPECTIONS . _,_
•
212 Main Street • Municipal Building
Northampton, Mass. 01060 r'
WORKER'S COMTENSATION INSURANCE Alt'1 U)AVIT
h -- — —— — —
(li ccnseeiperuii ttcc)
with a principal place of business/residence at:
' (p''hone#)____—_
(strcctici ty/statclap)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer prodding the following worker's compensation coverage fok- my •
employees working on this job:
(Insurance Company) (Policy Number) (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 compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
,r
(Name of Contractor) (insurance Compaay/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance CompanyiPolicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional thca if neeenar::o inel',;&i n er-ma:ion peateinng to all certradon)
( ) I am a sole proprietor and have no one working for me.
vfC,.1, I am a home owner performing all the work myself.
<<� NOTE:Pic'be ewuc slut while homeowner.a who etIploy panons to do c--,4,teosnr,corn:diea cr trpair\yori:on-dtscUi.1 cf
not mere than throe units in ranch the hrreowner raider or on the emu ads appurteesnt thereto Lt net UCrxrally vo,idcrod:o be
employers wrier the s'txkn e oariz cation Act(GL152.oa 1(5)),appliation by a homeowner for a license cc permit flea V cvi?, rx the
legal name of an employer under the Worica'a Compensation Act.
I understand that a copy ot this ctatemmt may be forwnrdod to tho Department of Industrial Aocideida'OfLoo of lzuura000 for the
coverage verification and that failure to sown coverage under section 25A of MOL 152 can load to the imposition of criminal pcealties
°assisting of a rune of up to S 1.500.00 andlc%impt-iscnur,a>i of up to one yw and civil pastilles in the form of a Stop Wen Ordc and a .
firm of S 100.00 a day against am.
Foe departantal uao only
Permit Number
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Signature of zee/Peril-Li- cc Teri-it --- -t----� �E
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DEPARTMENT OF BUILDING INSPECTIONS I
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060 nor
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction super:isor. The state defines "Homeowner" as, " Person(s)
.0 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)s
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
eLLAG ft . understand the above.
(Home owner)resident's signature requesti t1_ exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location (a_t) S-K •
L c Q V C . (