16B-044 253 NORTH MAIN ST BP- 2011 -0791
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map :Bloc 16B - 044 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: replacement windows /siding BUILDING PERMIT
Permit # BP- 2011 -0791
Project # ``' JS- 2011- 001305
Est. Cost: $27000.00
Fee: $70.00 PERMISSION IS HEREBY GRANTED TO:
Const. Cla ss: Contractor: License:
Use Group: TIMOTHY SENEY 061088
Lot Size(sq. ft.): 12893.76 Owner: LAFLAMME JEFFREY & TERRY
Zoning: URB(100)/ Applicant TIMOTHY SENEY
.-ice: n "< A IQ - -,RT -; 1 '9 0
Applicant Address: Phone: Insurance:
43 COUNTY RD (413 66 -0230
HUNTINGTONMA01050 ISSUED ON :4151201.1 0:00 :00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS /SIDING
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: NJ
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AN GULA ONS
Certificate of Occup � si nature
FeeTyue: Date Paid: Amount: .
Building 4/5/20110:00:00 $70.00
212 Maui Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
253 NORTH MAIN ST BP- 2011 -0791
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map.-Bloc 16B - 044 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate og ry: replacement windows /siding BUILDING PERMIT
Permit # BP- 2011 -0791
Project# JS- 2011 - 001305
Est. Cost: $27000.00
Fee: $70.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY SENEY 061088
Lot Size(sq. ft.): 12893.76 Owner: LAFLAMME JEFFREY & TERRY
Zoning: URB(100)/ Applicant: TIMOTHY SENEY
AT: 253 NORTH MAIN ST
Applicant Address: Phone: Insurance:
43 COUNTY RD (413 ) 667 -0230
HUNTINGTONMA01050 ISSUED ON :41512011 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS /SIDING
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 4/5/20110:00:00 $70.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
City of Northampton
GEC
Building Department
212 Main Street =�
Q 2 � , Room 100
N hampton, MA 01060
-587 -1240 Fax 413- 587 -12726
.�
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
Zone Overfi` D'istnct
Elm St. 'District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record - - - -.
Name (Print) Current Mailing Address:
Signature Telephone
2.2 Authonze Aaent:
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
Law
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) I zew, o'' Check Number ply
This Section For Official Use Onl
Building Permit Number: Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
f
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incompletelinformation
Existing Proposed Required by oning
This column to lent, filled in by
Building Dep
Lot Size m
Fronta e
Setbacks Front
Side L: __.._ R:
Rear
Building Height —
I�.
Bldg. Square Footage --- % --
Open Space Footage
(Lot area minus bldg & paved
- p arkin g)
# of Parking Spaces
Fill: 7
volume &Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO n DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON KNOW 0 YES Q
IF YES: enter Book Page and /or Document #'
B. Does the site contain a brook, body of water or wetlands? NO 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: mm ^~
C. Do any signs exist on the property? YES 0 NO
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
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 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 Alteration(s) E] Roofing
Or Doors iR1
Accessory Bldg. ❑ Demolition ❑ New Signs [[] Decks [M Siding $4 Other [ [:7]
Brief Descn tion of Proposed
Work: -i YMfe4x ,wa,2 i7�/�L�4 i /��✓ Q ,�N,7 S �f / /2/c 5�i�h' ��� /fOLlt /fl�r:�5�
Alteration of existing bedroom Yes No Adding new bedroom Yes K No
Attached Narrative Renovating unfinished basement Yes _ No
Plans Attached Roll - Sheet
sa Ife hciseranctrord'rtric�n tci exr"tlna losrdQrarfete hI foltc>vtEia
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 WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING !PERMIT
as Owner of the subject
property
hereby authorize f pv✓r e ,�/'
to act on my behalf, ' all rp6tt s re tive t work authorized by this building permit application.
Signature of Owner - Date
I, 1lNL ��,C„JiCy as Owner / A
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 pedury.
.mac 7 V
Print Name
::�6 3 A.? � /'�
Signature of Owner /Agent Date
SECTION 8 - CONSTRUCTION'SERVICES
8.1 Licensed Construction Supervisor / Not Applicable ❑
Name of License Holder f0 771Y 1 l� y ��Q I
License Number
✓iJ � N "7.� Oa✓ ' !Q U .�'��
Address Expiration Date
Signature Telephone
REt ItL: d=' llClinIt11pT t81Xt811hf3 i.. a,�,... _.. Not Applicable ❑
loll
Company Name Registration Number
sr�M� 1v z,<1 u
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 ....... (_ No...... ❑
y U
O'n
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 Investigations
600 Washington Street
Boston, MA 02111
www.mass gov /dia
- Workers' Compensation Insurance Affidavit:.Buiiders/ Contractors /Electricians/Plumb.ers
Applicant Information Please Print Legi l
Name ( Business /Orgaair�tion/lndividual): AeA4 YCi✓Xe
Address:
City /State/Zip: , 5!,,j22V AvW, 0106D Phone. #: 1 //3 /71
Are you an employer ?.Check the appropriate'bor. T e of project r
1.0 I am a loer with 4.. E3 I am a general contractor and I
Y 6. El New coistiuction .
employees (fall and/or part time)." have hired the silt- contractors
2 I am a 'sole proprietor or partner-
listed on attached sheet 7. ❑Remodeling
ship and have no loyees These sub - contractors have. .8. E] Dcaolit on
worldrig or me m an ad e l and have workers'
Y P . tY sdit a difion
[NO wa*lqrs f,. I�S1iIaliGe, - ..GOIap. �__ .'. ...
require&] 5. �]. We are a corporation and its 10 Q IIectrkal repairs or additions
3. ❑ I am a homeowner doing all work Of have xercised their l L - Phnabing repairs or additions
myself [No workers' comp. right of exemption per MGL 12: Roof repairs
�
152, 1 , and�we have no -
insurance rt34 c: ] t . (� 13.0 Other ' /Gl� 4 r /�
employees. [No workers'.
camp. Insurance requii�l
'Any applicant Shat chec3a box #Lmnst.also fill out ffie section b loo showing dx cornpesation policy informadaL
t Horneownes who submit this affidavit:inacatiag they = doing aR work and the hire outside contractors mwt submit a mw.affrdavit indicating sock.
1 Coatt2ctor3 that check this box mustanached an additional sbect showing the name of the sub - connectors and slate whedwror notthose-eatities have
employees. If the sub - contactors have employees, tliey must.pmvide their wozi=' comp.po n urnbcr .
. 4m an employer that is providing workers' cantpensatian insurance for. my employees Below is the policy and job site
information.
Insurance Company Name: .
Policy # or Self ins. Lic. A Expiration Date.
Iob Site Address: C' /Stir `
- — t P=
• Attach a copy of the workers'" compensation policy declaration page'(showing the policy number and _ezptratiou date).
Failure. ta secure covers e;as re under.Secttoa "13A ofIVIGL`c: T52 can lead to ffie '- sitiim of " -'
g 4 �o crunmmI pe aIhes of a
fine up to $ 1,500.00 and/or one- year as well as civil penalties is the foam of 11 STOP WDRK QRD£R and a fie
o up t o $250.00 a day against, the violator Be advised that a copy of this statement may be forw to the Offi 'cc, -of
Tnvestigattoiis of the D A for "u surance'coveraze verification
_do hereby certify under thep enaltres o. fperftpy41& - t a irrforma:ran�rovrded av "ifs _aadcorret _. _.
Si tare.
Phone #
O use oril . Do not write in this
fficrdl y area, tb be completed by city or tower offictaL
City or Town: Permit/Llcense # _-
Issuing Authority (circle one):
.'I. Board of Health 2. Building Department 3. City/Town CIerk .4. Electrical Inspector 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
homeowner."
The building department for the City of Northampton wants persons) who seek to use
the home owner exemption; - to act as their owrr 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 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 lime:
Date
Address of work
location