24A-026 (3) •
111111111111.11100 BP-2006-0296
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0296
Project# JS-2006-0429
Est.Cost: $3270.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Quinlan Builders 101707
Lot Size(sq. ft.): 7492.32 Owner: MICHEL DEE A TRUSTEE
Zoning:URB Applicant: Quinlan Builders
AT: 95 RIDGEWOOD TERR
Applicant Address: Phone: Insurance:
5 Hillside Dr (413) 549-5474 ()
HADLEYMA01035 ISSUED ON:9/15/2005 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE REAR ROOF
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 9/15/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
• 1 9 1.
'a` 3 . o e 5' n r t.fiT'Si ▪ " 4, a r L ax�,, .
Ct of Northam to atus ofPerrriit "" , *-S:,-A i"Building-Department G�urbl,Cut/D vevra �
212 Main Street er%Sep ic -ai a;i }-;, '1-,0,;
Room 100 /Well vai alp'i ' X ..g .» .t,
.,� "3'"� �...41.k...�2 i Y ..� `^ `i7, ,:.,fit,.
Northampton, MA 01060 Tw Sets�o▪ f`StCtuial Pa s =, 4s �'� � ,
phone 413-587-1240 Fax 413-587-1272 PiotTS,tYPlans '�' ''A� . ' `R_` w" '-
Oth r specify �.. _�.,�,-,��'�.- �"v<�� ,_ ,Z4-.47`
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
vo
SECTION 1 - SITE INFORMATION r • /
This section to-tie"aiiisprete iby"bfflic.,
1.1 Property Address: ' *'"
95 4' (j/ LQOS r 'r Map � , -;aid
Zone Overlay District 1,
Elm St__District CB District
SECTIONS - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ale fri , c(i I q 5 ,/Wiiewooci r erefc c
Na Print) Curre Mailin A dress:
�-(74( '4=201111.4011111.402011.11Kr, 3 yeti
l� Telephone
Signature
2.2 Authorized Agent:
TO/vt Qt)i'n, tt n a `t /t-tT Wet rn6e- gd,
Name(Print) Current Mailing Address:
5t/q - SLi L/
Signature Telephone
SECT0K3 - 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
6. Total =(1 + 2 + 3 + 4 + 5) ,3 r701, Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building,Commissioner/Inspector of Buildings Date
1
Section 4.
- ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF 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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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:
r ., r
6
SECTION5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 9
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
%Brief Description of Proposed W ✓
Alteration of existing bedroom Yes No Adding ne bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes ._,___No
Plans Attached Roll O • Sheet 0
agtfare wil itiTe anc or rad-ditrai to existin it o fs ng comple ,e iie 011iMir g:
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. Mascheck 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 AENT'OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, jLCi fill C G i e/ , as Owner of the subject property
hereby authorize I/i-1 0 U ill lei to act on
my b half, in all nutters relative to work authorized by this b ' in ' a lication.
.+„i
Signature of Owner Date
I, 1 0,4A (.0 t,►,/1(Gf "► , as Owner/ uthorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to best of my
knowledge and belief.
Signed under the pains and penalties of perjury. ,I,
Print Name
Signature of Owner/Agent Date
SECTION 8 .CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : /t7 M !f/�4 /G^ C S 0•5- l orr
License Number
a y r44 1— kci • 5 -/d ^o'
Address Expiration Date
.Cv 1 - /7 t/
Signatur Telephone
• Re -e lee u om rri s o ve;.en-: o n ;ac o. _ _ r; 2:' ' Not Applicable ❑
TO ,4-1 (Qt-ih (CIA I/p/ 707
Company Name Registration Number
kd ,Lcf n'lo f Lvq , 6 ' t '0(o
ress Expiration Date
T� (0./t Telephone SY 9 -St( L J
SECTION10 WORKERS'' COMPENSATION INSURANCE-AFFIDAVIT(MG.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 ❑
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 fo-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
�.tiwaPio _ �
o -
i (Giti tit N ttl:iliampfi111 f*=-
- ell f Alissacltnsctis• ={'=. r—.
ter= DEPARTMENT OF BUILDING INSPECTIONS 4__=:="if---
•
212 Main Street •' Municipal building '
Northampton, Mass. 01060 ` `' _
WORKER'S COMPENSATION INSURANCE AV14'1J)AV1T
•
(lice nseeil:crmittcee)
with a principal place of business/residence at:
VACkt/ trco eet . 14.) __(phone':; _ ._g i
•
(stye:t/city!:�totcJiip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following workers compensation coverage for in,
employees working on this job:
- (Insurance Company) - — (Policy Number) (Expirtion Date
(fr(I ama ole r riet , general contractor or homeowner (circle one) and have ' ' ed
the contactors listed below who have the following worker's compensaton policies'.
•
(Name of Contractor) (Insurance Company/Policy Number) (E ':ratica Da )
1
(Name of Contractor) (Insurance Company/Poi-icy Number) (Expiration Dat•)
(Name of Contractor) (Insurance Company/Policy Nu nb_r) (Ex4.iracn Da e)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dale)
(attach ad'!iticril ri>:ct ifrc.^cn■r :n inc.1*.wit ir.fc,r m :ionpeer-...it:;'..1i o:a:-._.,.$)
i
( ) I run a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself
NOTE:PkG3K be aware the while hcIncounccawiiyo ce npioy pa eceeee to<.)m izeeeaanet 0. r-rt:aim Cr repair w>.,,ii,•ra a&mil Le of
not more than throo t.•niti it wl;;t the 1'laeNt.a.w A rezi4 a Gr On the g-....::43 appkirter.rat thacto arc not£c rerally ca:::;eyed to be
employ=ur4ct the worker':c — .eatiar Ace(GLI52=1(5)),application by a homeowner fora Ucciu cc pcsnii::nay ...tree the
legal earns of an enspioyer under the Workers Comps-ration Act -
I understand that a cmy of this ctaten:cot any be foe warded to tin Dtiiertrri>t of lnrt..erial Accidents'Oifoo of 1r_:ur.a°a for tho
ooverige vcrif=titles and that failure to:sue coverts und.:r:canon 25A of MOL 152 can lead to the imposition of criminal perslliu
consisting of a fine of up to S 1.500.00 a^."'cx E---ruis.wznent of up to ere:year r:i civil penalties in the form of a Ste.;Were On;=er.d a
. fair of S100.00 a day agtintt m:. ,
For da-,uurnral apes only
Permit Nttmtxs _ _ __, /‘,.___ :_i ' ; ,\_
Signature of I.iccnr,c• ll/crmittcc --1 i. F'-
O�•Ct1AFfp2.
$ Olitp of Nort1ianmptomt Iz =,-it i
..j�: i A1gssachusetts — t=
t.stili _r;
ems_ f,. 4_;� _
- � —_
s7 4 DEPARTMENT OF BUILDING INSPECTIONS =g. — /;
INSPECTOR 212 Main Street • Municipal Building ',,,w ,,.
Northampton, MA 01060 .
e'
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sups:.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 pour), a rough building inspection (before work is
concealed). insulation 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
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