23D-151 (11) BP-2008-1062
Is#: A COMMONWEALTH OF MASSACHUSETTS
1111111111.1.1, 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-2008-1062
Project# JS-2008-001571
Est.Cost: $20000.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(so.ft.): 18513.00 Owner: DAVIS DEBRA L&
Zoning: URB Applicant: DAVIS DEBRA L &
AT: 147 HINCKLEY ST
Applicant Address: Phone: Insurance:
PATRICIA CANDEE GIBBS (413) 586-0787 ()
FLORENCEMA01062 ISSUED ON:5/28/2008 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL KITCHEN
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:
Fee'Fvpe: Date Paid: Amount:
Building 5/28/2008 0:00:00 $100.00194
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2008-1062
APPLICANT/CONTACT PERSON DAVIS DEBRA L&
ADDRESS/PHONE PATRICIA CANDEE GIBBS FLORENCE (413)586-0787()
PROPERTY LOCATION 147 HINCKLEY ST
MAP 23D PARCEL 151 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out pFee Paid / yAtib
Typeof Construction: REMODEL KITCHEN
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 F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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 Permit DPW Storm Water Management
Demolition Delay
./.,
a ,° 1/. 4,----/OWGes8
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.
+ Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/1NellAvailability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other S \-\- -
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR L H �O FAMI4 DWELLING
SECTION 1 -SITE INFORMATION 1.1 Property Address:
I ' 1 gA1 2 �oo$
J 1Fiis section to be completed by oft�ce
,Th
`. ��ili``rS
7 iwrC�(ley Map ' p O:�ot. I ; .. OICE�Unit
,.1
Fly .(ACQ ,AO pr6,6 Zone l-�� Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print)PC/ � Current Mailing Address:
G y,3 �6--07g,
Telephone
Signature
2.2 Authorized A ent: /1 4Jr .6
Name(Print) Current Mailing Address:
(/i3 -52 2-)2 7 (ce-e-eJ
Signatu Telephone
SECTION 3-ESTIMATED'CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit aoolicant
1. Building ' 7 Co. (a)Building Permit Fee
2. Electrical / (7 (b)Estimated Total Cost of
Construction from(6)
3. Plumbing / 0 Building Permit Fee
•
4. Mechanical(HVAC) Adu AG, ac - ,5
5. Fire Protection 11,5
6. Total= (1 +2+3+4+5) 2 d,C240C)- I' CheckNumber g `( iter) _
This Section For Official Use Only
_Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspectom oT buildings - Date
1 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
..A/kBuilding Department
_.__.._....a...
Lot Size
Frontage __. _��._ _..� �. —
Setbacks Front I i
. L
Side L:1 , ft= I L: ' R: _._,_
Rear
Building Height
Bldg.Square Footage s 3 . r-- % I �.._._
Open Space Footage % 1---1(Lot area minus bldg&paved ? # ---.
parking)
#of Parking Spaces ' — I
Fill: 1 . — W V
(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:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES C)
IF YES: enter Book Page: and/or Document# F
B. Does the site contain a brook, body of water or wetlands? NO ►1,4 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES O NO AS)
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 431
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,ex. vation,or filling)over 1 acre or is it part of a con ii our r plan
that will disturb over 1 acre? YES 0 NO /,�®
IF YES,then a Northampton Storm Wafer anM egement Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacemerndows I Alteration(s) ❑ 1 Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[CI] Other(DI
Brief Description of Proposed ` ``,, !mow Cub yr
Work: oke Ao ki'rriteo v--i erli, lv1 S ( 0 freVyd-tg
//
Alteration of existing bedroom Yes K No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
5a I- r use and or addition to existina housina. complete the foIlowina
a. Use of building: One Family INC Family X Other
b. Number of rooms in each family unit: 6 Number of Bathrooms I eA.c 4 u"'r
• c. Is there a garage attached? MP
d. Proposed Square footage of new construction. D 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. floodpiain 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 SE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING-PERMIT
I, , 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
1, Pan rc,� c. 6r bds , as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best cf my knowledge
and belief. •
Signed under the pains and penalties of perjury.
Q
Print Name
1 -icnature of Owner/Agent slate
SECTION 8-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
agdress - Expiration Date
3 cnature T eiecncne
Reaistered Home Improvement Contractor: Not ApplicableK
:cmcanv Name Registration Number
adress .Expiration Date
Telephone
ECTION 1:0-WORKERS'COMPENSATION wStJRAllV1ce AFFIDAVIT(M:G.L.G.132,::§25C(6))
+orlcers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit.•
gned Affidavit Attached Yes 0 No
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 10835.1.
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,von 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 f<i £ ,
r * ,.. The Commonwealth of Massachusetts
-I "= Department of Industrial Accidents
_ Office of Investigations
.....":"7"` 600 JI>ashinagton Street
Boston, MA 02111
.. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Oreanization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required): I
required.]
1.0 I am a employer with
employees(full and/or part-time).*
4. I am a general contractor and I 6. ❑New construction
have hired the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have g. 0 Demolition
working for me in any capacity. employees and have workers' 9 Building addition
(No workers' comp.insurance comp. insurance.:
5. 0 We are a corporation and its 10.0 Electrical repairs or additions
.F I am a homeowner doing all work
myself.3
officers have exercised their 11_❑Plumbing repair or additions
[No workers'co right of exemption per MGL
comp. 12.0 Roof repairs
insurance required.]t c. 152, §I(4),and we have no
employees. (No workers' 13.0 Other
j comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and stare whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job sire
information.
Insurance Company Name: _
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: ' 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 S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLA for insurance coverage verification.
I o hereby certify undder tthh��eepains and penalties of perjury that the information provided above is true and correct
Signature: fC-• Vr`7'0-4., Date: 57 'Vag
Phone#: 9/3 -P _c 7V'7
Official use only. Do not write in this area,to be completed by city or 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 I
6.Other
Contsct Person: Phone#:
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. 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 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).
sonotube holes (before pour). a rough building inspection (before work is
concealed). insu:ation 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
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 512 3/ K
Address of work
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