12C-004 4 7 , A4W, RP ; BP- 2011 -0478
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- 2011 -0478
Project # JS- 2011- 000783
Est. Cost: $3925.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD SCOTT 83108
Lot Size(sq. ft.): 32234.40 Owner: MACDONALD BETSY P TRUSTEE
zoning: RR(100) //WSP Applicant: RICHARD SCOTT
AT: 47 NORTH FARMS RD
Applicant Address: Phone: Insurance:
20 BULLARD AVE (413) 533 -6340
HOLYOKEMA01040 ISSUED ON. 1112212010 0.00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL FIREPLACE PELLET STOVE INSERT
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 11/22/2010 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
1
City of Northampton
Building Department s.
212 Main Street
Room 100 h
"V' Jorthampton, MA 01060
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 Pro a Address: This section to be completed by office
WZ X1415 Map Lit ilnif .
_FAa '�_ f\J CL D 1 Q u Zone Overlay Dis trict
it St'District C13-District
SECTION ,2 -.PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
, j �ti1 C
Na ;nt) Current Mailin g Add �ress:���
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
com leted by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Suilding Permit Fee
4. Mechanical (HVAC)
5. Fire Protection b Z D
6. Total = (1 + 2 + 3 + 4 + 5) - z- I Check Number
This Section For Official Use Onl
Date
Building', Permit Number: Issued:
Signatur .
Building Commissioner /Inspector of Buildings - Date
R �
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information i
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front '" j " "
Side " _.� 1
L: _ _ R: � L: � R: ` i
-
Rear ------ ..F
Building Height - --- -- °—
Bldg. Square Footage -- � %
Open Space Footage %
(Lot area minus bldg & paved
p arkin g)
# of Parking Spaces ?- -.• - -I
Fill: _ w
volume & Location) i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Z Page[ I and /or Document # _�
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
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 0 NO I
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 Q
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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
� b
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows ration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [m] Decks [0 Siding [0] Other [oj
Brief D� cnptigQ of 1I�p
Work osed t\ , `
: �V`a tf \ r` � r •.J'��.t- ��G � 5
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes � No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa: If'N�wril "` lfa�c�trr °en ``Ia na° ife"'
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 W HEN
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
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.
Pri Nam 1
ignature of Owner /Agen Date
d
SECTION 8 - CONSTRUCTION'SERVICES
8.1 Licensed Construction Supervisor Not Applicable 13
Name of License Holder L X I C-L N (1 b - Z �
9 c� 10 b
License Number
Address Expiration Date
Signature Telephone
00
e '�
c �3 ,. _ Not Applicable ❑
s A F;Q 0- kn t
Company Name Registration Number
Add; Expiration Date
Cam' Telephone 5:11 gz)
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....... 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 hive to perform work for you under this permit.
The undersigned "homeo rtifies and assumes r onsibility or liance with the State Building Code, City of
Northampton Ordinances, !t WanLo a Z ' ng La a d State o Ma s usetts General Laws Annotated.
Homeowner Signature _� 4b
• T
.. sY
The Commonwealth of Massachusetts
Department of Industrial Accidents .
Office of Investigations
U 600 Washington Street
Boston, MA 02111
• www.mass gov /dia
-Workers' Compensation Insurance Affidavit:.Builders/ Contractors /Electricians/Plumb.ers
Applicant Information �-- Pleas P Le
U
Name ( Business /Organization/Individual): _ 1 /�
Address:
City /Stat&Zip: L a Phone . #: Yt
7 Are you an employer? Check the appropriate box: Type of project (required):.
I am a employer with 4.. I am a general contractor and I
employees (foil and/or part-time).
* have hired the sub- contractors 6. ❑ New construction
2.401 am a sole proprietor or partner- listed on the attached sheet y- ❑ Remodeling
shilr and have no loyees These sub - contractors have. 8. (] Dernoli8on
w m capacity.
any capaci eniployees_and have workers'
working for .
;T,cg„ rac i - mc +, TM �„ #:_ II inlding aid on
[Na workers Comp: 10. Electrical repairs or additions
required ] 5. We are a corporation and its ❑ ep
3 I am a homeowner doing all work officers ha xercised their 11. F Plumbing repairs or additions
right of exemption per MGL
myself [No workers comp. 12:�].Roofrtpairs
insurance required:] t c. 152, § 1(4), and we have no 13. ❑ Other
employees. (No workers'
Comp_ incirranc =quired.].
`Any applicant that checks box #.1 narst.also fiII out the section below showing de irworkas' compensation policy information:
t Homeoamcrs who submit this afdavit.indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
1 ConuactMs that check this box must-attached an additional sbeet shoving the name of the sub-contractors and state whethenr not those erttities have '
e mploye e s. 'If th e sub- contrwtors have employees, d ey must.pravide their work=' comp. policy number.
la m 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 /StafelZap:
Attach a copy of the workers' - compensation policy declaration pagge the policy number. and expiration date).
Failure, to secure coverage: as required under Section 25A of 1ViGT c. T52 can lead to tiie imposition of ciiminal penalties of a
fine up to $1,500.00 and/or one- year as well as civil penalties is the form of a STOP WORK -ORDER and-a Rw
of up to $250.00 a day against the violator Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coveraze wcrification
I do. hereby certifjy under the p and p , f of- pe jwy that the information pro
vtdeif above islrue -and cnrred
Si tore: �•
Phone #�/+ 7 .
Official use only. Do not write in this area, to be completed by ctty or town offlkw
City or Town: NrmitUcense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk .4. ElectricaUnspector 5. Plumbing 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, 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 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 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
�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 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 tome.
Date
Address of work
location