18D-053 111111111111" { . BP-2008-0607
GIS#: COMMONWEALTH F MASSACHUSETTS
CITY OF NO THAMPTON
Lot: -028 PERSONS CONTRACTING WITH UNREGIS ERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARAN Y FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-0607
Project# JS-2008-000931
Est.Cost: $4790.00
Fee: $25.00 PERMISSION IS HEREBY G NTED TO:
Const. Class: Contractor: License
Use Group: HOME DEPOT AT HOME SERVICE 126893
Lot Size(sq.ft.): Owner: GENCARELLE DARSHAN&
Zoning: GI Applicant: HOME DEPOT AT HOME SERVICES
AT: 80 DAMON RD #2101
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341-9401
Workers Compensation
WORCESTERMA01 607 ISSUED ON:1/2/2008 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:
FeeTvpe: Date Paid: Amount:
Building 1/2/2008 0:00:00 $25.0021593
212 Main Street,Phone(413)587-1240,Fax: (413) '87-1272
Building Commissioner-Anthony Patillo
•
Department use only
City of Northampton Status of Per-nit:
Building Department Curb CutlDriveway Permit
212 Main Street Sewer/SeptidAvailability
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 ATONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This sec�ion to be completed by office
1.1 Property Address: 1�
Map Lot " Unit
91a01011b Zone Overlay District
1
Elm St District 1 CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
I9.1 Ownor of Record:
4 4
Name( rint) Current Mailing Add •
Telephone rJ
Signature
2.2 Author". Agent:
_ - hA • 316 ewilko.odl111Jt204 I"4 DI 7
NamI / Current Marling Address:/
0 2f
Sign. re Telephone
SEC ION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building I I I D (a)Building Permit Fee
•
2. Electrical �-- (b) Estimated Total dost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total= (1 +2+3+4+5) q /Ci) Check Number 01/ ` - 3 'p25-`
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector ofBuildmgs 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
Frontage
Setbacks Front
Side 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 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 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT 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 u
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 W]pdows Alteration(s) n Roofing n
Or Doors [t
Accessory Bldg. ❑ Demolition ❑ New Signs [t]] Decks [Q Siding [0] Other[0]
1.
Brief Description of Proposed ^_ _n4t60_,Foconienta)weilor) r��
Work:
Alteration of existing bedroom Yes No Adding new bedroom Y s No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition toe 'sting housing, complete the folly/Ong: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 AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
. .
I, 4. , 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
/I. `�L I 1VJ _._ , 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 t . s and p +es of perjury.
D
Print Name
r
v
Signa re of 0 er/Ag t Date
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable 0
Company Name Registration Num r
Ad ess •
mm G Expiration Date
(, U I Telephone qD1 q J p? 03
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
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 ofMassach ,etts
r, r 4 Department of Industrial Accide is
I •
Office of investigations
t 600 W%ashington Street •
, =c--' Boston,AL4 02111
www.mass.govldia
Workers'Compensation Insurance Affidavit: Builders/Con actors/Electricians/Plumbers
Applicant Information Please Print Lecibly
Name(Business/Organization/Individual): :�/ ��.
Address: C 55 Vi6W- frt.), A�
•
1
City/State/Zip: KL(A (2 '/ Phone.;. c3a) 7 `Y
Are you ployer?Check the appropriate box: Type of project(required):
1. am a employer with tf� 4. 0 I am a gene-al contractor and I 6. ❑New construction
employees(foil and/or part-time).* have hired the subcontractors
2.Q 1 am a sole proprietor or partner- listed on the axached sheet. 7. 0 RemodelingI shi~and have no employees These sub-contractors have g. 0 Demolition
working for me in anycapacity. e]2] loyew and have worms'
rking aP ity * 9. ❑Building addition
[No workers'co,;.:,.insurance comp.insurance. 10_❑r—lectzicaI repairs or addiYrtions
required_] S. j] We are a corporation and its
3.❑ I am a homeowne`doing all work officers have exercised their 11.0 Plumbing repairs or adriitions
myself o work,.-rs'co right of exemption per/vIGL
comp. 12.0 Roof repairs r�
insuuance required.]t c. b2,§1(4),and we have no —
employees. [No workers' I3.Q'Other )�
con*.insurance required.]
-----".saiTapplicant that ragas uox n1 must also ttit Oct the sermon oeiaw showing then-workers'compensation p icy mformation.
t Homeowners who submit this affidavit inrikating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
'Contractors that check this box nnutamehed an additional sheet showing the name of the nib-contractors and sate whether or not those entities have
employees. If the sub-contactors-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 sae
_information.
Insurance Company Name: IA')+-Lf 1)! ___ , 6_,,
Policy#or Self-ins.Lic.#: 9- t-Hm , Expiratio Date: 1
Job Site Address: c:2-6-----91 ✓ City/State/Zip: \"14 OIOk
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expira 'on date).
Failure to secure coverage as required under Section 25A of MGL c. in can lead to the imposition of criminal penalties of a
1im•up to$I,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 8250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the ► • for Ms-... e coverage verification.
I do hereby terrify und, thi'.a' 10• ,enirtrips ofperjury that the information provided above is true d correct.
Gg
xre=.—.—� ---1 / -1. - —.-----
Date: _
Phone#: %/ c35 J3�
t T it
Official use only. Do not write is this area,tb be completed by city or town official
_Cy or Town: --_____ - --P-ermit/License R11
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. Ciry/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
6.Other i
I
Contact Person: Phone T:
•
E assacilusets I�l 4=-
�, c
DEPARTMENT OF BUILD-DO INSPECTIONS
212 Main Street • Municipal Building
INSPECTOR
Northampton, MA 01060
l
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of-Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sup^:-•, 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 buildingdepariment for the City of Northampton wants any person(s)who seek to
use the hone 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).
sanotube holes (before pour). a rough building inspection (before work is
_ concealed).insulation inspection (if required)aud_a final buildino.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-w4rk 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 to me.
Date
Address of work
location
a ' ;a
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.0 LICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE • E
AND ARE PART OF THIS CONTRACT
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