12C-087 BP- 2011 -0456
GIs #: COMMONWEALTH OF MASSACHUSETTS
amok W11,10
; 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 -0456
Project # JS- 2011- 000736
Est. Cost: $3450.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RONALD KEITH 085204
Lot Size(sq. ft.): 10018.80 Owner: JONES ELIZABETH E
Zoning. URA(100) //RI/WSP Applicant: RONALD KEITH
AT. 28 RICK DR
Applicant Address: Phone: Insurance:
5 BIRCH MEADOW DR (413) 584 -5589
HADLEYMA01035 ISSUED ON :11/16/2010 0:00:00
TO PERFORM THE FOLLOWING WORK.- & SHINGLE 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:
FeeTvpe: Date Paid: Amount:
Building 11/16/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
s
City of Northampton a
Building Department t
212 Main Street
Room 100
J ..
Northampton, 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
This section to be completed by office
1.1 Property Address
rK (C.1t Map Lot Unit
�LJC.L� -a m�, C7 i dC.� Zone QYerlayDstract
Eim St °Dtstriet CB. District
SECTION - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) Current Mailing Address:
yr '3S'7�
Telephone
Signature
2 AA uthorize ed l
d Age
Name (Print) Current Mailing Address:
--1_'
Signature Telephone
SECTION 3:- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. 34/y'� a (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= 0 +2+3+T+ Check Number
This Section For Official Use Onl
Date
Building' Permit Number: Issued;
Signature:
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 i
Side L ' = R € L: R:
--
Rear
Building Height J
Bldg. Square Footage
Open Space Footage_ % -
(Lot area minus bldg & paved
par
# of Parking Spaces
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES Q
IF YES, date issued:; j
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book 1 Page and /or Document #'
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES 0
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 0
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 Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors 1:3
Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [[] Siding [0] Other [p]
Brief Description of Proposed n
Work:
Alteration of existing bedroom Yes _& No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement es Via? No
Plans Attached Roll - Sheet
z ' ` "` ' fi M z 1�'` " R
Oa aillo A w ..� ; ' a mp•: ,ta`"•a C. `<, •.
sa 1t� +u ho ISe fa c wi XI Ing
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'- T8 BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT:
as Owner of the subject
property
hereby authorize
to act on my behalf, in all m tters rela ive to work authorized by this building permit application.
Signature of Owner Date // /
I, t w rk , , ) y 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 Owner /Agent Dat
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervis Not Applicable ❑
Name of License Holder: (10'),w Kl2 1� CS F) ,zC
License Number
Address Expiration Date
Signature Telephone
S uRea � i t sferbil =lal item "ri11rCirrJ<ent <iricfr G1 „ .� Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c.152, §- 25C(6)j
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 hom eowner.
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
v"
T
The Commonwealth of Massachusetts
Department of Industrial Accidents -
Office of Investigations
600 Washington Street
Boston, MA 02111
w www.mass gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers
Applicant Information Please Print Legibly
Name ( Business /organiiatiow dn_t- ,id ual): .
Address: Q`�i : I, Von J ��..
City /State/Zip: Q4 0 l, 01W Phone. #:
Are you an employer ?.Check the appropriate•box: Type of project (required) :.
1�S I am a employer with Ci 4, El I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time). * have hired the sub- contractors
2 I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship and have no egIoyees These sub - contractors have. .8. Q Demolition
working for me in any capacity. =VIo_yees and have workers'.
9 Burl
[No workers'. insisance - comp. m „ ++�� # .. 0
required:] 5. E] We are a corporation and its 10.0 Electrical repairs or additions
3. El I am a homeowner do' all work officers have xercised their 11. Plumbin r
mg ❑ . g epairs or additions
myself (No workers' comp. right 6f exemption per MGL 12:Q.Roofrepairs
insurance req�� ] t C: 152 § 1(4); and we have no 13.� Other
employees. [No workers
comp. insurance required }.
* Any applicant Shat checks box #1: must.also fin out the section below showing drirvorkers'. compensation policy information.
t Homeowners who submit this affidavit.indicating they = doing all work and then. bus outside contractors must submit a new affidavit indicating such.
IConuaetors that check this box must.attached an additinnal sheet showing the name of the sub - contractors and state whether-or not.those entities have
employees. If the sub - contactors have employees, they must provide their workers' comp. policy number.
I am an employer that isproviding workers' compensation insurance for my employees. Below is the polity and job site
information.
Insurance Company Name:
Policy # or Self ins. Lic. #: Expiation Date: -
Job Site Address: City/StafelZip:
Attach a copy of the wor4rs' declaration page'(showing the pglicy number. and expiration date).
Failure. to secure coverage: as regturea nueTer.Seciion 25A: ofIvIGL c: 15z can lead to me imposition of crirmn�l penalties of a
fine tip to $ I,500.00 and/or one. -year imprisonment,' as well as civil penalties is the form o£ a STOP WORK ORDER and a f=
of up to $250 00 a .day against the violator Be advised that a copy of this statement may be forwarded to the Off'ce of
Investii�atzons "of the bIA for insurance coverate veril7cattTon
I do hereby certify under the p-and penalties ofper�my that the inforarationprovrded abuv . nark corr
St attire: ate lI lj�4 /LS
Phone #: 4- /J - a'
_.
Official use only. Do not write hi this area, to be completed by city or town offrciaL
.City or Town- Permit/Llcense #
Issuing Authority (circle one):
.'1. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical Inspector 5. 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
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 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
�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 __ —L
Address of work
location E3 d'.i t K TJL,