23D-143 (5) 411111111111111. BP-2005-0207
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: Deck Addition BUILDING PERMIT
Permit# BP-2005-0207
Project# JS-2005-0253
Est.Cost: $3000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 13503.60 Owner: RICHMOND PATRICIA M
Zoning:URB Applicant: RICHMOND PATRICIA M
AT: 1 WINSLOW AVE
Applicant Address: Phone: Insurance:
1 WINSLOW AVE O 586-3783 O
FLORENCEMA01062 ISSUED ON:8/30/04 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 12 X 16 DECK & CONSTRUCT NEW
DOOR TO DECK
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 8/30/04 0:00:00 1604 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2005-0207
APPLICANT/CONTACT PERSON RICHMOND PATRICIA M
ADDRESS/PHONE 1 WINSLOW AVE FLORENCE SS(o-371 ,
PROPERTY LOCATION 1 WINSLOW AVE
MAP 23D PARCEL 143 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid /u°7( 105°
Typeof Construction: CONSTRUCT 12 X 16 DECK&CONSTRUCT NEW DOOR TO DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF STATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan •
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commis ' n
-/ 4,14/ 1!?/9 04/
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
f -
Department use only
� —City of Northampton Status of Permit:
j1 EC E Q V�p LS [ IJiIding Department Curb Cut/Driveway Permit
-1! 212 Main Street Sewer/Septic Availability_
AUGLo)p,H... Room 100 Water/Well Availability
I G 2 3 2004 1-ampton, MA 01060 Two Sets of Structural Plans
phone 113-587-1240 Fax 413-587-1272 Plot/Site Plans
DEPT OF BUILD."G INSPECTIONS Other Specify
PC-"Tuw" ;?,"i,PAe
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
I '' ii fl �
W 1 ✓\ 51Bw �e Map FJ Lot Unit
0 C f,sCQ11'1iA- O i Q Cp a Zone ,1`""— Overlay District
l
Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: M I J i
Name t) Current Mailing Address:
/41-44 yl3 �KL — 37f13
Telephone
Signature
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
1. Building �p0 (a) Building Permit Fee
32. 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) OQD Check Number /ea 5'-0 —
This Section For Official Use Only
Building Permit Number/fooy— off? 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
Lot Size , 2>SC Lk
Frontage
Setbacks Front i 4' � ti 1 i +`
to tZa
Side L: l q R: C bts 2.-, L: ff i R: i e Z
rs
Rear �q r S 2,0
Building Height c
145-
Bldg. Square Footage % Sk
x Ic
Open Space Footage
(Lot area minus bldg&paved 4 �j � 0
0'
parking) 2 5S I X -i C. s l
#of Parking Spaces 2_
Fill:
(volume&Location) �4.111e— c1V..kYt�
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO V 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 V' 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 /7
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 WORK (check all applicable)
New House 0 Addition 0 Replacement Windows Alteration(s) 0 Roofing 0
i Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks Siding[ ] Other [ )
Brief Description of Proposed Work: j2'X tb' O 61/4-01:20\t erso (9,ANActt S&YOWN
Alteration of existing bedroom Yes / No Adding new bedroom Yes No �c29•12
Attached Narrative 0 Renovating unfinished basement Yes / No
Plans Attached Roll D - Sheet/
5171f I"e�+ blare' n drefizTaaitiTato efealtnrd o"us!t conuSl`#e he fo{1owr g:
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 koevk.t__ ck_bV-Q OeY rCC
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
(4)A-V f, r�u , 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
Signature of Owner/Agent Date
C'-
•
SECTjdN CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
Re 5 e>e a orne.morove :-ent= ontracto Not Applicable 0
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 3.D 'WORKERS',COMPENSATION 1NSURANCERAFFIDAVIT(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 acccptable 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 Genera] 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 a Lo al Zoning Laws an tat of assachusetts General Laws Annotated.
Homeowner Signature
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L)EPARTMENT OP IIUILDING INSPECTIONS 4
212 Main Street ' Municipal Building •
Northampton, Mass. 01060 • air
WORKER'S COMPENSATION INSURANCE A.1+1wAVfl'
i
•
1, .
(liccnssdlcrmittcc_)
with a principal place of business/residence at:
•
----- ----- ——_ -- (phone'=; _ -
(strcelJcity!statc ip) — _ —__
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the followins: worker's compensation coverage for my
employees worlang on this job:
- (insurance Company) (.colic. 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 workers compensation policies:
(Name of Contractor) (insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Lnsarance Company/Policy Number) 1.'ExF,i r;anon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(ttLich adiiticral shed if anomie^to incl•Y e i:for:•a:ia:,:=._.::r.E,t.e1i c: :t•cr.•)
)
I am a sole proprietor and have ob one `.':irking for me.
14\1
am a home owner performing all the workmyself
NOTE:please be aware tiara Wile bon-downers%.:so employ;•e-xc:s to ct) Nsit-+,are,ea-c rar_ien cr tt,p'av v.":i: -dwci!i_g of
not More than throe units in t.'L•it_tt the 1.,..:n essw r redid-al or of:ha g"a'-reis a,pputer.rr thccto e.c nit me--rally ox:t:c:r:d:3 be
ratployca under the Watitee:t e�.,.3,,:_tam Act(GLl5?.�-s 1(5)),application by a hotneotvrer fora be uc CC p-sati::: ...'tir,:e th'
legal natus of e.n employer under the Worker's Co--op _..lion Act.
I underhand that a copy of thin etat.ctu ct r•-uy be forwrvtfed to the Depart.-nerd of IndiriJ Aoci'emts'Offioo of 1:✓.Y.-?b for the
coverage verification tool that failttrc to glee cov-:Lgo ur'.3cr aection 25A of MOI.152 can lead to the imposition of crimi.•L.l penalties
cvoiistata of a fmc of up to S 1,500.00 ao&cr i^privie.lest of up to ore.year:r a:d civil penalties in the form of a Ste?Wort O:tir aced a
fur of S100.00 a day ag.in.:t rm. . .
Fur dq;artrnatsl u►o may
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,... .4"=- DEPARTMENT OF BUILDING INSPECTIONS I'� _E_� /=
INSPECTOR 212 Main Street • Municipal Building '�>ow 5,.,r
Northampton, MA 01060 .
01
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 D LAY the project unt. suc time as the proper permits and inspections are
made
I, C M understand the above.
Date(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
2 ay
Address of work
location
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