15B-003 (2) lr BP- 2010 -0473
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- 2010 -0473
Project # JS- 2010 - 000654
Est. Cost: $500.00
Fee: $25.60 PERMISSION IS HEREBY GRANTED TO:
Coast. Class_: Contractor: License:
Use Group:
Homeowner as Contractor
Lot Size(sq. ft.): 20995.92 Owner: PROPERTY GROUP INC THE C/O ALISON P CHILDS
Zoning: URA(100)/ Applicant: PROPERTY GROUP INC THE C/O ALISON P CHILDS
AT. 625 SPRING ST
. applicant Address: Phone: Insurance:
625 SPRING ST (413) 582 -0280 O
LEEDSMA01053 ISSUED ON. 111412009 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 8 X 16 SHED
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
1'nderground: 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 11/4/2009 0:00:00 $25.60
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -0473
APPLICANT /CONTACT PERSON PROPERTY GROUP INC THE C/O ALISON P CHILDS
ADDRESS /PHONE 625 SPRING ST LEEDS (413) 582 -0280 Q
PROPERTY LOCATION 625 SPRING ST
MAP 15B PARCEL 003 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp Permit Filled out AL
Fee Paid `
Typeof Construction: CONSTRUCT 8 X 16 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
____Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission ' Permit DPW Storm Water Management
Demolition Delay
1 2 ' 124
Signahare of ding Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
;� � � �� �Department�seonty� '
City of Northampton Statusbf Pesmlt
Building Department Ctrfrltlfway errntt
212 Main Street Sewefl'�iw cAvailabilt
f adz a
Room 100 a� 2 rr[abilt s
M y
�V
Northampton, MA 01060 Ttinrt��e f "Gtrstu a�lans
phone 413- 587 -1240 Fax
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
LV
SECTION 1 - SITE INFORMATION
Thie SeiDtion to 'be completed by office
1.1 Property Address
/> �L) Map - — -- Lot Unit
� Zone , Overlay District
Elm St District CB District
SECTION! 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT'
2.1 Owner of Record
Name (Print) Current Mailing Address:
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) Gheck Number
This Sartinn Fnr nffrtial LJSP 0111
Permit Number: Issued:
Building Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
L
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 m m -
Side L: __ ._.. R _ .., L ,,...- _.. R ..._.._.._.,. __._:
Rear ------
Building Heifht
Bldg. Square Footage
Open Space Footage % _ - •- ,.G•,��
(Lot area minus bldg & paved m
p arking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW YES
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KN YES
IF YES: enter Book Page' ~ _ and /or Document #,
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
1
proposed�anges fo or additions of signs intended for the property ? YES � NO
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 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicablei ^ ,�
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors F
Accessory Bldg. Demolition ❑ New (�
Signs [0] Decks [M Siding [O] Other [0]
Brief Description of Proposed f �/
Work: ��- �'_ ry 6 `�" d y
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa. `if.New house'and or add�trort to eicsteinq housing corriplete.th'e following:
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? (; 1 6
f. Method of heating? Fireplaces o Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction Jk
i. Is construction within 100 ft. of wetlands? Yes �/ Nof Is construction within 100 yr. floodplain Yes ✓ - No
j. Depth of basement or cellar floor below finished grade
k. Will 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
L AA �e U-27 as Owner of the subject
property /
hereby authorize f —
to act on my behalf, in 21111 matters relative to work t onzed by thjs building permit application.
�, ( G.
Signature of Owner Date
:. . ..........
C.(�
, as Owner /Authorized
Agent hereby declare that the statements an 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.
Is,T..1 ,1
Print Name
Signature of Owner /Agent Date
J
SECTION 8 - CONSTRUCTION SERVICES
1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
I—A ( ft License Number
Address Expiration Date
_
1
Signature Telephone
9.. Recr "stered;.Elomelnproveinent Contracfior , ,,, Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
S ECTIO N 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" w_ s 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.
Alco be ads icvd that 41rith rt-ferenre - to Chapter 157 (Wnrkems' 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�ire - to perform work fot�yo�a�znd"erthispermir - - - - -- -" -_ ___ ".__
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
N - 6fthrrftptofi - r - m - ces,` a e - s- General•- Laws - Annotated.
Homeowner Signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office oflnvestigations
600 Washington Street
Boston, M4 02111
;� _�•` www.massgov/dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Orgam zation/Individual):
Address: 2
City /State /Zip: Phone.
Are you an employer? Check the appropriate box: Type of project (required).
1. ❑ I am a employer with 4. I am a general contractor and I
employees (full and/or part time).
* have hired the sub - contractors 6. ❑New construction
2. ❑ I am a sole proprietor or partner listed on the attached sheet. 7. EJ Remodeling
ship and have no employees These sub - contractors have. .g. [] Demolition
working for me in any capacity. employees and have workers' 9. Q Building addition
[No workers' comp. insurance comp- insurance.t.
required.] 5. We are a corporation and its 10.0 Electrical repairs or additions
3. I am a homeowner -dein� all-work- - - -- -- -__ offce=ha xercis ��t,taeir - 1 �_Plua3bing -repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. Q. Roof repairs
insuran required:] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. i suran required}
"Any applicant -that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then. hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
lam an employer that is providing worker x' compensation insurance for my employees. Below is the policy and joh site
information
Insurance Company Name:
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site Address: City /State /Zip
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as I required under Section 25A of MCTL c. 152 can lead to the imposition of "criminal penalties of a
fine up to $1,500.00 and/or one =year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. 1�e advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification
__do_hereby: certify nd thepains and p s fperjury that the information provided above i -&ue azL correc
tore: ^ l ate �.9 _
Phone #:
EAth nly: Do not write in this area, 10 be completed by city or Town official
: Permit/License #
ority (circle one): ealth 2. Building Department 3. City/Tow n Clerk 4. Electrical I nspector 5. Plumbing Inspecto -- on• Phone #-
J
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, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
_r-egal Th . inch ction proe r� uires that the building department be calle to
inspect work at various stages, which include foundation /footings (before backfili),
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 occunancv
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
- - - - -- --- pemii t, ,, .-in-conjunction -to the -bu ing-p ermit_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.
VVV .(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Address of work
location
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Prepored For
PPOPER`Y GROUP, 1 1C, � &
Scale: 1'=SV Dote: JUNE 14, 2006 And A,""wp 01Q Z
This It G btortg" inspection P lot. Do not use th converse .�Ft, Sw to is p � 01001) plan+ to erect f "c;ev, - V*Wubbery or oneillory structures,
rpr lendirg purposes oMy, AS distancias approximate-
To:
and t`114ST AMERICAN TITLE 1 CC}1rtFAINY
To the hest of my know edge, informatinn and bd>lef,
i her^eby report that I havt et:amined the prerrisen and � HOLD
that this inspection plot shots all aosem,6mts, o €AY RYx 4
encroachments and buildings, and thot this ,property
Fe not Located in the 100 yvur flood zwe.
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