23D-194 (2) BP-2008-0420
GIS #: 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: BUILDING PERMIT
Permit# BP-2008-0420
Project# JS-2008-000618
Est. Cost: $1967.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq. ft.): 156816.00 Owner: BIRCH HILL LLC
Zoning: URB Applicant: John Corbett
AT: 70 RIVERSIDE DR
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:10/18/2007 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:
FeeType: Date Paid: Amount:
Building 10/18/2007 0:00:00 $25.002703
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
Department use only
City of Northampton Status of Permit:
iluildirtg Department Curb Cut/Driveway Permit
`LGk3 212 /lain*treet Sewer/Septic Availability
i30m Water/Well Availability
1*rii fi, MA 01 060 Two Sets of Structural Plans
pie 41, j6 1240 Fax 4137587-1272 Plot/Site Plans
�n 0� Other Specify
AP.CATIO O CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
147 Map Lot Unit
Zone Overlay District
rwu er5iL
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: C' •w+a... O/ Syr
131>—G A />I j LL LLC . f '10 `3G Aar, r- D rode r0
Name(Print) Current Mailing Address:
y'i 4 Q 97V—
Telephone
Signature
2.2 Authorized Agent:
jc>Inv`- '.-3 e- ii ,S hiMcc�� s% L�,.�z� �� oro>
Name(Print) Current Mailing Address:
Sgnature 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
2. Electrical (b)Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection Q
0. Tidal-(1 I 2 13 I ' 5) //I 1 — (:hark Nnmher ,2•7 3 ' _✓
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector— - g ofKildm s 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
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 Q DONT KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES Q
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 Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
.............................. ........... ...
Needs to be obtained Q Obtained 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 O
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 Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
4 ,
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacements indows Alteration(s) n Roofing n
Or Doors �9�
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[J Siding[0] Other[O]
Brief Description of Proposed— — Cr
Work: 5) t L V),L-r VA Luc— a
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 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 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
•
, 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 _J ..A1 Cc/ • .0 (( , as Owner/1fhonzeg
(erghereby declare that the statements and information on the foregoing application are true and accurate, to the best of�jy, 17.0 edge
di Id belief.
Signed under the pains and penalties of perjury.
Print Name _
/41/170
Signaturfr-of Owne/Agen Date
SECTION 8-CONSTRUCTION SERVICES •
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable 0
Company Name WINDOW WORLD Registration Number
56 Dim ock Street • eVe f S.
Address Leeds,MA 01053 Expiration Date
586-8712 Telephone_
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
k The Commonwealth of Massachusetts
Department of Industrial_Accidents
F J ul O fice of Investigations -
f3 , y 600 Washington Street
C=_7 Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
Applicant Information Please Print LegibIv
Name(Business/Organization/Individual): WINDOW WORLD
56 Dimock Street -
Address. Leeds,MA 01053
•
City/State/Zip: 5 1ga.s.t.
Are you an employer?Cheek the appropriate box: Type of project(required):
1.0 I am a employer with 4. I am a gene•al contractor and I 6. ❑New construction
ogees(fall and/or part-time).* have hired the sub-contactors
2.erica a sole proprietor or partner- listed on the attached sheer 7- 0 Rcmodelmg
ship a_+d have no to ees These sub-contractors have g_ 0 Demolition
working for me in ascapacity. Cmgloye and have worke s' 0 o addition
�� 3' 9. Butldin`
INo worke s'comp.ins-'-azice comp.insurance.:
required] 5. .0 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself jNo workers'comp. right of exemption per MGL 12,0 Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 12. Other
•
comp.insurance required.]
----•*-Attrappticant that cnasa oox at.must aso nil out me secnon maw snowing these wori s'compensation policy information.-- _.
t Hmneownes who subxnrt this affidavit indicating they are doing all worts and then hire outside contractors mast submit a new affidavit indicating such.
"Contractors that check this box must.anached an additional sheet showing the name of the sub-contractors and sate 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 site
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 ofMGL c. 152 can Lead to the imposition of criminal penalties of a
fine up to S1500.00 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
Investications of the DLA for insurance coverage verification.
I do hereby certify under the pains and penohiPs of perjury that the information provided above is true and correct.
____sr tee:__. _.. Date: /d//S� 7
Phon Ir: �e:Y 777 /Z.-
Officiai use only. Do not write m this area,to be completed by city or town offrciaL
Citi or Town: _ —
-__.__-..---- __-____ --Permit/License# .
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
6.Other
Contact Person: Phone
. , ,
3 y I a-3acirusrts ^'
�. a ==c
DEPARTMENT Or BUILDING LNSPEGTIONS ,ti =__
212 Main Street • Municipal B.Building
s"
INSPECTOR \��
Northampton, MA 01060
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 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).
sonotube holes (before Dour). a rough building inspection(before work is
concealed). in-sulatio-n inspection (if required) and_aJinal builclino 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
•
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