31B-014 (3) 111 PROSP>rCT ST BP-2003-1203
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:31B-014 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: renovation BUILDING PERMIT
Permit# BP-2003-1203
Project# JS-2003-1473
Est. Cost: $4500.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 8799.12 Owner: KLEIN RICHARD&FAY ANN
Zoning:URC Applicant: KLEIN RICHARD & FAY ANN
AT: 111 PROSPECT ST
Applicant Address: Phone: Insurance:
111 PROSPECT ST
NORTHAMPTONMA01060 IS,SflED ON:6/24/03 0:00:00
TO PERFORM THE FOLLOWING WORK:RENOVATE BATHROOM
POST THIS CARD SO iT IS VIE 7''LE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: P nup,h: House# Foundation:
Driveway Final:
Final: Filial:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: O i!_ Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BL. REVOKLI) BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: 1...:cipt No: Date Paid: Check No: Amount:
Building 1410 0.0.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
• R
•
'.11)i Departrpentaue'to61P A" ., F
City of Northampton Status of Permit: s) :, - y , 4 •
Building Department Curb Cut/Driveway:Permttv_i
212 Main Street Sewer/Septic Availability
• Room 100 Water/Well%Availability F y s "h. c°
Northampton, MA 01060 Two Sets of Structural Plansx . '>.:
phone 413-587-1240 Fax 413.587-1272 Plot/Site Plans : 1 ' -
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address This section to be completed by office
cree#- Map Lot Unit
00 Alk • 1041V1, W3A OIOp
Zone Overlay District ^_
Im St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Fill°
kev#1)j al 19ikrzt c-thicef-
Na 0 Print) / Cur t Mai . o A dres : 41...
/ tech...1.,
Telephone
Signature 00
4
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
1. Building I a) a( ) Building Permit Fee
— --
2 Ele :.I ic'I 4 �/ (b) : :timated Total Cost of
— Construction— '/W Construction from (6) - _
3. Plumbing 4 n cao Building Permit Fee
4 Mechanical (HVAC) (��_
5. Fire Protection
6. Total = (l + 2 + 3 + 4 + 5) ____I Check Number-14t"-- _
I This Section For Official Use Only/
Building Permit Number: AP- 2Oa3 /2o3 Date issued: f. 2,�j
Signature: _/77.°77/ 4F
- ----
Building Commissioner/Inspector of Buildings Date
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
(py.�� Building Department
Lot Size I(t) &If.,,- 5414tti../
Frontage ( (0(0 j""••t
Setbacks Front
Side I,: I L:.__671,.7fr_____
Rear Y
Building Height 11 1- 4 A--
Bldg. Square Footage n %
Open Space Footage
(Lot area minus bldg&paved ► l 14 /
parking) (04.
#of Parking Spaces
Fill: .----„-.
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO X DON'T KNOW _ YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO y 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 X 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. there any proposed changes to or additions of signs intended for the property ?YES
No
IF•YES, des?ribe size, type and location:
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition 0 Replacement Windows Alteration(s) Roofing 0
Or Doors 0
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ I
Brief Description of Proposed Work: 4' I1 1./ .1119.::0_
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement -_Yes - No
Plans Attached Rolf 0. Sheet 0
6a. If'New:h•ouse,and or addition to existing-housing, complete the following
N7141-
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 AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
•
, as Owner of the subject property
hereby authorize to ac; on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
CT ^ r•`/ � �1" _, 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.
Sign d under the pains and penalties of perjury.
Pri N e
•reetL.—.,-
f✓
Sig ature of Owner/Agent 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 Regis a me lmpr"oveme f aiffi cto , ' ; . N4, „went Not Applicable 0
Company Name Registration Number
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; .= e tom -A caner wemp $ _
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 referenc . Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not result' n Death)of the Mass chusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for yo, der this permit.
The undersigned"homeowne ( ,•rtifies and assu les res on ' ility for compliance with the State Building Code,City of
Northampton Ordinances, Sta , apd cal Zonin, aws State of Massachusetts General Laws Annotated.
/I ♦
Homeowner Signature P
• oQTitAI-ti'1.
• ti° Gii1) of \Taz"tlJti111pfon
b �� '! 18•
A eJ =.i 6 y fi3asaach'ttsclls' ibT___-__.
7_,__—__:
P
"rz"--,„„ DEPARTMENF OP BUILDING INSPECTIONS ' .M.4—
212 Main Street • Municipal 13uildin `_�_
l 'o
Northampton, Mass. 01060s.
WORIC-ER'S COMPENSATION INSURANCE AF IDA V1T
I -- --
•
(liccns::eJpermittee) —
with a principal place of business/residence at:
— .(phone )
(strcet/city!sttat_einp)
do hereby' certify, llnoer the pains and penalties of pe.rjury, (11ai. -
( ) I am an employer providing the followine ',vorkci s coin cnsar+on covera.,e for my
employees working on this job:
(Insurance Company) (Policy Number) (E):oir:.tion Date) -
( ) I am a sole proprietor, general contractor or homeowner (circle one) anti have hired
the contractors listed below who have the following worker's compensatiorr :;olic:es:
—
(Name of Contractor) (Insurance Con-it-nay/Policy Dgay/Polici NuniC•c:�
m (1::::"era:ion Date)
(Name of Contractor) (Insurance Compaany/Pollci Number (I.`c.I` :Ion Date)
(Name of Contractor) (Insurance CompanyiPolic: Numbed (t x :razior: Date)
(Name of Contractor) (Insurance Company/Policy Number) (Exrirrition Date)
(attach:.daiticral ct.:et if..-.en.:-:to ixl•xle t:t ormaax p•stain{r ..:all or:tra" .)
i
( ) I am a Sole proprietor and have no one working for me.
( ) I am a horre owue. per-Lorrning all the work hi:ysci'i
NOTE:pleinae L•c nhruc that while herneovt,r_ra wba criploy p C.Tvr3 to cb r _:_.aaec,C.r n:et.:Yh CZ:cp:ai:••"-:i:c^t,t«ttli.g cf
not mcYe than a roc units i;;svfir t the Isonn,awirs rcaidcs or of the 4:y'j 2.pfllrtt- +that's0 e.rt ttt:t Eerr1111y Ctr.:i:::rtti to tL
cmpioy'ca under the tvcr''kees c in,ruthcn Act(GL1 S2,zs I(S)),appL•_:.tic::by a hotntowna fore licchx Cr i-s:::::::r._:tr.-,tiny L:c
legal rtatuta of an o5ploy or under t .,Worker's Comr,ornation Act
I unde^rtand that a copy of(hi,etatrnsaat may bo fotwnrdod to tbo lhporta,a,t of Inel ,•riel Accidents'Office of Inssin r:x for the
coverage vcrtficatioa and that failure to.i!o rc cove ago under sex:ion 25A of MOL.152 can Ir_d to the imposition of cr-min_1 pctaltics
consisting of a lux of up to S 1.S00.00 atrol'or tz prtaormic.]t of up to on'ytzr and civil pCrlaRica in de form of a Sir,'Wert Ord---.-and a
Into of 5100.0(3 a thy agaia•.1 tthc.
- _____--
For dcputnrrtal u.c only
Pclrnit Ntl.Intx:.r --_- _---_-__�
Signature of L.icc: •
----- -.— ,Ltpl; t —i
. at;q.;t<_ :,eJPer:nittc� 1i:y-c? 1 �L:
O,-T%AMp7.
• 04,
Cifp of Northampton )7
c� ) y`_ (j o ...,..,„„... g -F
'4"2-40' DEPARTMENT OF BUILDING INSPECTIONS !,
INSPECTOR 212 Main Street • Municipal Building '`a,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 his/her construction supc:-,•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)t
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, V2461k Alt0 e' l)3 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 m .
Date 6 OS
Address of work a
i 116,5
,,tite,e__.
location