31B-083 25 EDWARDS SQ BP- 2012 -0068
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map 31B - 083 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF 'BUILDING PERMIT
Permit # BP- 2012 -0068
Project # JS- 2012- 000100
Est. Cost: $10000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVE MINER
Lot Size(sq. ft.): 2962.08 Owner: ELLIOTT WARREN P & NAOMI M C/O SHERRY TAYLOR
Zoning: URC(100) Applicant. DAVE MINER
AT. 25 EDWARDS SQ
Applicant Address: Phone: Insurance:
347 NEWTON ST (413) 533 -0481
SOUTH HADLEYMA01075 ISSUED ON. 7/1 0 / 7 0110:00:00
TO PERFORM THE FOLLOWING WORK.- Roofing
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 7/19/20110:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
City of Northampton
Building Department
212 Main Street
Room 100 `
Northampton, MA 01060 F,
phone 413 - 587 -1240 Fax 413 - 587 -1272
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
Map` Lot Unit
T 5- o verlay District
,;Efm 5t District CB, District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: n D
. f r ��1 r �� '''� f � � t.-or � S
N me (Print) Current � ling Address: Q 1
M VI3 7 th( Z
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 ermit 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) !U D UC Check Number
This Section For Official Use Onl
Date
Building Permit Number. Issued:
Signature: l
Building Commissioner/inspector of Buildings 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
Rear
Building Height
Bldg. Square Footage 0110
Open Space Footage 0 /0
(Lot area minus bldg & paved
# of Parking Spaces
(volume & Location) IL
A. Has a Special Permit/Variance/ Finding ever been issued for/on the site?
�� �� ��
NO �~� DON7KNOYV x�� YES v��
IF YES, dateisuue&
IF YES: Was the permit recorded at the Registry ofDeeds
0 NO [0N7 KNOW 0 YES
r I I
IF YES: enter Book and/or Document#
�� ��
B. Does the site contain a brook, body nf water orwetlands? NO �~ �� � DONTKNOVV «~� YES �~�
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs to be obtained »°~� Obtained x~�` �ate|ssued'| �
�� «_� ' 'L___-______�
C. Do any signs exist on the propert �� �� y7 Y[� »�� NO v��
|F 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
|F YES, describe size, type and location:
E. Will the construction activity disturb (clearing, gradingexcavation, o, filling) over 1 acre orioi1 part ofa common plan
that will disturb over 1 acre? YES K � NO K �
�� ��
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
MINNOW
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all aoalicable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing F-1 Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding [o] Other [C7]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
s`a lftrnl.,hose. acii��i��ii�lta eict�aa �islci.;ca 'p[eiefaftta r c:
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 AUTHOR1.ZATIO14 TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT`
I , as Owner of the subject
property
hereby authorize �'6 J C ° ► i�
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of f 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 A� �
under the pains and penalties of perjury.
', /'� i ✓t r ,/�
Print Na e
Signature of Owner /Agent Date
SECTION 8 - CONSTRUCTION` SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder : _ 1 C {Y� �� r T 5 11 S
License Number
Address Expiration Date
Signature Telephone
9 RaisCered'[xe Imrrorrriertorilctir�: r ..,. F ` . ..�.. , Not Applicable ❑
l l t D A `l
Co any Name Registration Number
Address Expiration Date
Telephone 3 '�4
SECTION 10- WORKERS' CpMFENSATIQN 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...... 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 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
• T
The Commonwealth of Massachusetts
Department of Industrial Accidents -
Office of Investigationg
600 Washington Street
Boston, MA 02111
www.mass gov/dia _
-Workers' Compensation Insurance Affidavit:. Builders/ Contractors /Electricians/Plumb:ers
Applicant Information Please Print Legibly
Name ( Business /Organinfion/Individual):
Address: 3 "� 7
City /StatelZ.ip: 4 o- \ ./17 A- Phone. #:
Are you an employer?. Check the appropriate -box: T e of ro'ect r
4.. I ='a general contractor and I P I r (�I =.
1,21 a employer with ❑ g 6. R New coistruction .
employees (fall and/or part-time). * have hired the sub- contractors
2-01 am a 'sole proprietor or partner- lea on- the:attached sheet. 7 ling
ship and have no employees .. These sub - contractors have S. ❑ Derbolilion
working for me in any capacity employeres and have _workers' Hi10
[N® wort=?. comp: ; Tra,►e - .:c9mp. inetrrantr
r ed 5. ❑ We are a corporation and its 10 Q IIecirical repairs or additions
equir. l office hava
rs yescised their 11 Plumb" r
3. ❑ I am a homeowner doing all work . , ❑ . mg epairs or additions
m elf- o workers' co � of exemptioii per MGL
ys [N comp. 12.TRoof repairs
insurance required ] t c. 152, § 1(4), and we have no .
employees: [No workers' 13. ❑Other
comp. insurance requimAj.
'Any applicant that checks box #1- ffitst.also fill out the section beiawshowing tb**o&=s'- compcnsation policy information
t Homeowners who submit this affidavit.indicstIIag they are doing all work and the'. hire outside conh26tors twist submit anew a0davit indicating su&
'Contractors that check this box mvsi.attaehed as additional sheet showing the name of the sub-contractots and stax whetluror notthose cadties bave
employees. If the sub- eontracfors have employees they must provide 9teir workers' comp-poHcYntanber.
I am an employer that isproviding workers' compensation vrsurance for my employees Below is the policq and job site
information.
Insurance Company Name:
C� `� - �o lion Date: /
Policy # or.Self- -ins. Lic. #: �., 7� _ `� ° Expua
Job S Addres t:.,P f e� . S e City /Sta&2/ p:
-Attach a copy of the workers' compensation policy.declaration page the pq he number and irstloa date .
Failure. to- secure coverage: as requited under Section - 25A: ofMGT e: T52' eau Iead to ffie imposition of criinin penalties of a
fine up to $1,500.00 and/or one.- year as weR as civil.penalties in the form of a STOP WORK ORDER, and a fine
of up to $250.00 a day against t3ie violator Be advised'that a copy of this statement may he for warde to t he:025 ce of
Tnveshttahoiis `oftheIPi for iisirnaiice'coveraze vei a f
I do hereb certi u e auu and enalties o
C%y� P p. fperjury.that the in" ormatton rovrdedlrbstv cr> )) aadrarr PC1 '
Phone
Official use only. Do not write in this area, to be completed by ctty or Town `bfjuraL
.City or Town: _ Nxmit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical Inspector S. PIumbing Inspector
6. Other
Contact Person: Phone #:
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. 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
homeowner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemptioz0a 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 back fill),
sonotube holes (before your), 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 insuections 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
�ermits 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 DIELAY 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
Date
Address of work
location