24D-284 (10) BP-2008-0600
GIS#: COMMONWEALTH F MASSACHUSETTS
CITY OF NO THAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGIS ERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-0600
Project# JS-2008-000928
Est. Cost: $2500.00
Fee: $25.00 PERMISSION IS HEREBY GR4NTED TO:
Const.Class: Contractor: License,`
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 5270.76 Owner: ATELA PAU
Zoning:URB Applicant: ATELA PAU
AT: 186 CRESCENT ST
Applicant Address: Phone: Insurannc•e:
186 CRESCENT ST
NORTHAM PTON MA01060 ISSUED ON:12/28/2007 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WOOD•TOVE
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 NORTH• PTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu•anc Si•nature:
FeeType: Date Paid: Amount:
Building 12/28/2007 0:00:00 $25.001677
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
{ Department use only
r 'W, C of Northampton Status of Permit:
V�� \ \1� ' 18uil ing Department Curb Cut/Driveway Permit
L'�� - 212 Main Street Sewer/Septic Availability
„LCO� Room 100 Water/Well Availability
DEC 2 Northampton, MA 01060 Two Sets of tructural Plans
phone 413-587-1240 Fax 413-_587-1272 Plot/Site Plans
Other Specify;
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH ALONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
C/ 1.1 Property Address:
Id 6 CgEse ivr S T. Map Lot Unit
/V c r''l oin-t p7bp I Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
9.1 ownor of Rarnrri• 1
?A u ATE LA
Name(Print), /� Current Mailing Address:
/�— G'v' C 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
trj1. Building (a)Building Permit Fee
2,.Sn j) (c f v&) •
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 /697 7 11(4d•s
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector ofBuildings - Date
Section 4. ZONING Alt 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 Q 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 Q
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
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) I I Roofing n
Or Doors I]
Accessory Bldg. ❑ Demolition ❑ New Signs [IZI] Decks [I] Siding[0] Other[D]
Brief Desion of Proposed
Work: f N'criptS74LL ] OD S TO V a
Alteration of existing bedroom Yes No Adding new bedroom Yes 7 No
Attached Narrative Renovating unfinished basement Yes 1, No
Plans Attached Roll -Sheet
6a. If New house and,or addition to existing housing, complete the following:
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 Nq.
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
111111111111,111111111.11111111/1111.111111111
rI AA_ Te /fix , as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true nd accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
✓ Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: I Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: .:1-tr,gi, Nut A-plicble ❑
Company Name Registration Number
Address Expiration Date
Telephone
i —
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 ❑
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 respo ibility for compliance with the State Building Code,City of
Northampton Ordinances,State Local Zoning La s an State of Massachusetts General Laws Annotated.
/ Homeowner Signature vim— c
v
' The Commonwealth of Massachusetts
"---4—"
_,5.,_ Department of Industrial Accide�rits
Office of Investigations
600 Washington Street
Boston,MA 02111
`".• www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Piumbers
Applicant Information Please Print Legibly
Name(BusinessJOrgaaiz-ationandividmi1):
Address:
•
City/State/Zip: Phones:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with s ❑ I am a general contractor and I :I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
' 2.❑ I am a sole proprietor or partner- listed on the attached sheet_ 7. ❑Remodeling
ship and have Io;a These sub-contractors have g. 0 Demolition
workiztg, for me in any capacity.
employees and have worms'
ya. 1. 9. ❑Building addition
(No wo es'cow.insurance comp.insurance. 10. Building
repairs or additions
required-j 5. 0 W e arc a corporation and its ❑
3.❑ I am a homeowner doing all work officers 3 their I
11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemptiohavenexercise per NIGL 12.❑Roof repairs
insurance required_]t c. 152, §1(4),and we have no
employees. [No workers' I3.0 Other
comp.insurance required.] `
-----"Xarappucant that cncks oox jri must also nil out the seenon oeiow snowmg their workers'compensation policy inforzanon.
T 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 mttstar-ached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. lithe subcontractors"have empioyem,they must provide their workers'comp.policy numbs.
Iam 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-ions.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
Brie up to S 1500.00 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 ce • under the pair td en,lt's of perjury that the information provided above is true and correct
_Qr,att. I -- Date:
Phone#:
y Officialo cite only. Do not write in this area,to be completed by thy or town official 1�
_Ci r Tow --P n: __.:__- ermitiLicense#
Issuing Authority(circle one): `
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing inspector i
6. Other
Contact Person: Phone
• �
04,
.�� a53aciluscts ! t===
..
DEPARTMENT OF BUILDThG INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building ,� v
Northampton, MA 01060
I
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supr:-',4.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_whho constructs more than one home in a two-year period shall not be considered a
home owner."
The building=-depaFtmeat 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 bacidill),.
sanotube holes (before pour). a rough building inspection (before work is
_ concealed-). insulation insnection (if required)and final huildina.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
util 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
•
/I, ?AU f TE L/9- 4t/-- , understand the above.
✓ (Home owner/resi• re
questing e uesting exem tion)
q a p
I will call to schedule I required building inspections necessary for the building permit
issued to me.
— - Date I R C / 200 -------
1
Address of work
location /Q6- 0 reS CC }1 ,(t,