23A-022 (5) 21 PARK ST BP-2004-0166
GIS#: I COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A-022 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0166
Project# 3S-2004-0247
Est. Cost:$1000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MICHAEL MCKENNA 132070 ,
Lot Size(sa. ft.): 10802.88 Owner: PLATT CONSTANCE A
Zoiihctb:x .r :44nolicent`MICHAEL MCKENNA
AT: 21 PARK ST
Applicant Address: Phone: Insurance:
209 POMEROY MEADOW RD (413) 527-1266
SOUTHAM PTON MA01073 ISSUED ON:8/13/03 0:00:00
TO PERFORM THE FOLLOWING WORK:REBUILD CHIMNEY
0.
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: Q l Gf-l‘.. 43_.
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOL N
ANY OF ITS RULES AND REGULATIONS. / .44
/7/4e.'
Certificate of Occupancy Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 8/13/03 0:00:00 1848 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
21"0 .ST$ BP-2004-0166
GIS#: COMMONWEALTH OF MASSACHUSETTS
maxwooto CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# P-2004-0166
Project# 3 -2004-0247
Est.Cost: 1000.0
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MICHAEL MCKENNA 132070
Lot Size(sq.ft.): 10802.88 Owner: PLATT CONSTANCE A
Zoning:URB Applicant: MICHAEL MCKENNA
AT: 21 PARK ST
Applicant Address: Phone: Insurance:
209 POMEROy MEADOW RD (413) 527-1266
SOUTHAMPTONMA01073 ISSUED ON:8/13/03 0:00:00
TO PERFORM THE FOLLOWING WORK:REBUILD CHIMNEY
POST THIS JARD 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 PERM I MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS ULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 8/13/03 0:00:00 1848 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
_,__ I ` ", se-partent•lsel'bnl .:
y(��f tfiampton (stab of Perm t°, � ;y. ,',..4 .. ,
` .A;
iltRng Dartment Curb`Cut/Drvewy e it r �,yyam�,;',
212 Ma Street Sewer/Septic A'aitabi4Eiti*Aa 4 kw
Pr
1 r
AUG i 2 2003 Ro `100 water/We(F�J'�11{j/ -A � �t
Northampton, MA 01060 i vio SE is of Structural P,lans '�,-,: ti '
hone A 13 587 1240 Fax 413-587.1272 ,F�� )t, tQ_ t'lan :„ '. 'i'V�,
EtiOF QUIlOING INSP CTION
NORTHAMPTON,MA 01060 ,)thci .)pecify �
APPLIC TION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
I
SECTION 1 - SITE INFORMATION
1.1 PropertyAddress: � This section to be completed by office
1 ?1'tA c S� er `1—
� Map — Lot_ Unit
`C)r 4 014 Zone Overlay District
1 Elm St._District CB District
SECTION 2 - P•OPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of R•cord:
(,nv % - VIA* ) \ PiN/? 7-77-6-CJ
Name(Print) rye M ing A r ss
Ce.^.,, "ram i 6� `p ''� �o
(,i -- — Telephone
Signature
2.2 Authorized Agent: «
Name(Print) Current Mailing Address:
Signaturk Telephone
SECTION 3 - STIMATED CONSTRUCTION COSTS
item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
Building 1 f 7 a a 4 CO (a) Building Permit Fee
2. Electrical 1 (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
F►• Mechanic I (HVAC)
5. Fire Prote tion
6. Total = ( + 2 + 3 + 4 + 5) Check Number vk —
This Section For Official Use Only
Building Pe mit Number: Date Issued:
Signature: _
L Building Commissioner/Inspector of Buildings Date
Suction 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
parki ig)
#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:
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House El Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑Ye_b0
New Signs [ I Decks [ ] Siding [ ] Other)(]
Brief Description of Proposed Work: \1() c v'V\ 1200 r (h()
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 • Sheet [
6a; IfNew h'ouse°aid'or addition to existing housing, complete the following:
a. Use of budging : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a ::arage attached?
d. Proposed '.quare footage of new construction. bimensions
e. Number of stories?
f. Method of eating? Fireplaces or Woodstoves Number of each
g. Energy Co servation Compliance. Mascheck Energy Compliance form attached?
h. Type of co struction
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 buildi g 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 ac: on
my behalf, in a I matters relative to work authorized by this building permit application.
d — =� t ��,`-�- t /63
Signature ofdla. Date
, 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 the pains and penalties of perjury.
Print Name
Signature of Owrer A ent Date �d
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : ffl\ir . O `-lot/ev►nM 0 S 7069
License Nu ber
Qom _a Alft61 S6d'i, M ll d o6 tr
q�p � Q 107j Expiratio Date
1614111 1' ' 9 t 3- .Sa)-/a66
Signature Telephone
9. Registered Home I nip rgvem'enrContractor „�',;;.; V- Not Applicable
Applicable 0
6
Company Name
Registratio�Nmber
FYI�
Address Expiration Date
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,OwnerExe101-1 n
Th- current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
an. to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as .0 s ervisor. CMR 780 Sixth Edition Section 108.3.5.1.
D•'coition 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
st ctures. A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Su h"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
re• onsible for all such work •erformed under the buildin• I ermit.
A acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
co pletion of the work for which this permit is issued.
Al.o be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
E ployees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
yo hire to perform work for you under this permit.
T e undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
NI rthampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
H meowner Signature
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DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 ,"
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I
(I iecrisec/F.,er mittce)
with a principal place of business/residence at:
`_(phone'') — -
-- (strcc.lcitylstotc zip)
do hereby certify, under the pains and penalties of perjury, that. -
( ) I am an employer providing the following worker's compensation covera:,.e for my
employees working on this job:
—
(Insu anti Company) (Polio—Number) (Expiration Date)
( ) I am a sole promietor, general contractor or homeowner (circle one) anti have hired
the contractors listed below who have the follo ving worker's compensation r.•ehic:es:
(Name of Contractor) (Lnsurancc Cornaany/Policy Number) (L-x r:raucn Date)
(Name of Contractor) (Insurance Company/Policy Number) (Exc alion Date)
(Name of Contractor) 0nsurance CompanyiPolicy Number) - (l?x,:.ration Date)
(Name of Contractor) (Insurance Company/Policy Number) _ (Expiration Date)
etLidt acleittiocal ef�et if::a-cna: :.. .....xic i:::-r::u:ion 7,7.=taininr, e11 c:<:.ra .r..`
I am a sole propiie ur and have no one working for are.
) I am a home owner nertor Ming all the work myself
NOTE:plc:sc be awuc the:•. ilc hri<rcou:r-ra u;ao cm ley pr-c-:s to cb canicasncS tier.-talcum tit:;fair,•:i er.•.:«c1li.",c:
not more than throe lulu in'tidyy. l:x:ti^owi cr raidcs ct ott the p-,x::r's appurtenant thereto a...-c tot caw-ally o:..::: : :a he
employ,---a uca cr the twti:cr'a c,—:..::sa::cn Act(GI-152'.1 1(5)),rppl:n ion by a hombowncr for a liccuc(X p-ra:i:::...: c... crk-c till
legal etatus of an xnployer under t's Woriccet Compensation Asti
I undc.-rtand that a copy of thin etat=v.eat may bo forwarded to t1)0 Drtxirtmcnt of Ind6adrial Accident?Office of!::;ur anA for the
covalst verification and that failure to recurc coves-Igo ten 3cr sectics 25A of MQt.152 can lead to the imposition of criminal petal;:cs
comisting of a fmc of up to$1,300.00 a:t.'nr in:prison:m=1i of up to one you AM civil peruhies in d-.from of a Ste,:Wort Ord.cr and a
flan of S100.00 a day against rn:.
For depattnxrtal lac Drily
/ Permit Ntlmtx r _ —
.000 /"....701......00 .7 C/1**'
ignaturc of I.. cnr;c fPcrnt ittr ., I k.
�� Critp of Nartlt�.mptan • 1_ _*
�.��� %.,t')t� jigassachusctts ; _'_ "l_
*5r ,: °-
4 DEPARTMENT OF BUILDING INSPECTIONS , =. `= /_
INSPECTOR 212 Main Street • Municipal Building �`,,,4
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 Lis/her construction sup•:::,isor. 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
ho eowner will be responsible to make sure that the trades hired secure their proper
per its in conjunction to the building permit issued, and that they get their required
ins ections. Failure of the individual trades to secure the permits and inspections as
regtttired 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