23D-150 (6) s i
B P-2008-0102
GIS#: COMMONWEALTH OF MASSACHUSETTS
11111111111111. 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-2008-0102
Project# JS-2008-000164
Est. Cost: $8250.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ROBERT BENOIT JR 088335
Lot Size(sq.ft.): 46173.60 Owner: NORRIS LAURA B
Zoning:URB Applicant: ROBERT BENOIT JR
AT: 22 NONOTUCK ST
Applicant Address: Phone: Insurance:
66 UPPER ST (413) 586-2162 ()
B UCKLAN DMA01338 ISSUED ON:8/8/2007 0:00:00
TO PERFORM THE FOLLOWING WORK:ENLARGE & REBUILD DECK W/ROOF OVER &
RESIDE HOUSE
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 8/8/2007 0:00:00 $50.00729
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2008-0102
APPLICANT/CONTACT PERSON ROBERT BENOIT JR
ADDRESS/PHONE 66 UPPER ST BUCKLAND (413)586-2162()
PROPERTY LOCATION 22 NONOTUCK ST `
MAP 23D PARCEL 150 001 ZONE URB 1 cr
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out � /
Fee Paid
Typeof Construction: ENLARGE&REBUILD DECK W/ROOF OVER&RESIDE HOUSE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 088335
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN ATION 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 Commission
4.....jj
0 VO 37°7
Signa e 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 Offi e of
Planning&Development for more information.
I
5 _ .
( Department use only
City of Northampton ���' l ►b�tatq*of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street AUG - 1 L Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of1Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plahs
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
Ne , -4-,, c, 5-1-. Map Lot Unit
t ,° �t ' L M - Zone Overlay District
t ..� Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
r. I
Name(Pri Current Mailing A ss:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
-14 Lc-0 0.
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) P SO. �' Check Number 7219 1
This Section For Official Use Only
Date
Building Permit Number: 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 Zoning
This column to be filled in by
Building Department
Lot Size � q2oSDI✓
Frontage / S qJ, ,qt)
Setbacks Front f U Q0 /
14>
Side L:/2D R: 30 L: R: /5V
Rear J 6 0
Building Height
iJ
Bldg.Square Footage a o a 1,
%
Open Space Footage %
(Lot area minus bldg&paved _di , e;#
parking) V �J�/
#of Parking Spaces a_
Fill:(volume&Location) N 4-
A. Has a Special Permit/ .riance/Finding ever been issued for/on the site?
NO DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit r e at t e istry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT 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:
E. Will the construction activity disturb(clearing,gr • . excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
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) Roofing
Or Doors
Accessory Bldg. Demolition New Signs [ ] Decks Siding if,6. Other[ ]
Brief Description of Proposed q
Work: 15 - -.- II a d-e 4- k-1 e K. /ti ge �r/oi r o o Y r- .S o c/e k o c� c
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ^- No
Plans Attached Roll -Sheet
6a.If New house and or addition existing housing, complete the following:
a. Use of building:One Family Two'amity Other _
/)
b. Number of rooms in each family unit: Ai."' Number of Bathrooms
il
c. Is there a garage attached? ✓V;, /
d. Proposed Square footage of new construction. �� Dimensions " 3 1 ` 6 x- / t.7
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves >v -4- Number of each //7)-
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction W..)--It
i. Is construction within 100 ft.of wetlands? Yes pc, No. Is construction within 100 yr. floodplain Yes_ o
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
I, h e,..,t,, ,� (.. -g- ,r L e . 1 ,as Owner of the subject
property I
hereby authorize L�J 4 c I- t 1?- 't ti ,o ,
to act on my behalf, in all matters relative to work authorized by this building permit app ication
ature of er Date
I, o J ,. -1- rgf h b i -- ,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 Na
i,7 r 4.—. :,4- V ---Y-- -----X --- 9- i A '-)-
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: / 1 Not Applicable 0
Name of License Holder: o .fig r— 4- 1 �-0 1" l / Cl� ' .. c
License Nu ber
1.2 i I r i z-� . L;1, .,_ if..„ I AAA- 0 I Z 3 -S /Z 2 b p -3—
Address I Expirati n Date
L ,e.„1.4- ( ----e L57g 6 - aI6a
Signature Telephone
9.Reuistered Home Im rovement Contractor: Not Applicable 0
WIZ( --7•4�l,.o,' / 21 Z /22,
Co nv Name Registr tion umber
A dress Exp. anon to
4 bt- ,.,- 6-'7
11 X.c,k_....4-• <1 Telephone J'E3,6 a/.6 'D
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 ik, No 0
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
wwwecnass.i?ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbersb Legibly
Applicant Information Please
''
Name (Busiiness/Organizationflndividual): r,, r ft 4,r. 41,{
/I �v`i ( �- vc LLB
b
Address: (A. rI L.✓ ' +'
City/State/Zip: "few k k h ci-
Al yt 0 ( 3- 8 Phone# ---l/ (i, `l S— a'-I S
Are you an employer? Check the appropriate box:
Type of project(required):
1. — I am an employer with 4. — I am a general contractor and I 6. I Construction
Employees(full and/orpart-time)* have hired the sub-contractors 7. Remodeling
2.
2. — I am a sole proprietor or partner- listed on the attached sheet. I 8 Demolition
Ship and have no employees These sub-contractors have
Working for me in any capacity. . kers' comp.insurance. 9. — Building Addition
[No workers' comp.insurance are a corporation and its 10. — Electrical repairs or additions
required.] 'icers have exercised their 11. — Plumbing repairs or additions
3. — I am a homeowner doing all work right of exemption per MGL 12 Roof repairs
myself. [No workers' comp. C. 152, ' 1(4),and we have no
insurance required.]H 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.
H Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
I Contractors that check this box must attach an additional sheet showing the name of the sub-contractors and their workers'
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: For all FCCIP towns 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.
I do hereby cer fy un er the pains a aides of perjury that the information provided above `c true nd correct.
t , / Date: f
Signature: d'4-� 7
Phone#: —1 R 'r A f c — g-,...2 6
Official use only. Do not write in this area,to be completed by city of 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
Phone It:
Contact Person:
5
Information and Instructions
provide workers=compensation for their employees. Pursuant to
s defined er 152 r ery person in the service of another under any contract of hire,express or implied,oral or
Massachusetts General Laws Chapter 152 requires all employers to p
this statute,an employee i
written.@
An employer is defined as Aan individual,partnership,association,corporation or other legal entity,or any two or mere 0C the
foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the owner of a dwelling
house having not more than three apartments and who reside therein,or the occupant of the dwelling house of another who employs
persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall
not because of such employment be deemed to be an employer.@
MGL Chapter 152, '25C(6)also states that Aevery state or local licensing agency shall withhold the issuance or renewal of a
license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced
acceptable evidence of compliance with the insurance coverage required.@ Additionally,MGL Chapter 152, '25C(7)states
ANeither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until
acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority.@
Applicants
Please fill out the workers=compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,
supply sub-contractor(s)names(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability
Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to
carry workers=compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit
may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date
the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not
the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers=
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance
license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The department has provided a space at the bottom of the affidavit for
you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the
permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license_.
applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under AJob Site
Address@ the applicant should write Aall locations in (city or town).@ A copy of the affidavit that has been officially stamped or
marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A
- —new affidavit must be filled out each year. Where a homeowner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,please do
not hesitate to give us a call.
The Departments address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
w ww.mass.govidia
6
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