17A-049 s 40 NOW Aa
vwY' BP- 2010 -0865
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 -0865
Project # JS- 2010 - 001287
Est. Cost: $10000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groun: WILLIAM PICHETTE 71053
Lot Size(sq. ft.): 11107.80 Owner: O'CONNOR LOTUS P
Zoning: URA(100) //RI Applicant: WILLIAM PICHETTE
AT. 152 BRIDGE RD
Applicant Address: Phone: Insurance:
P O BOX 454 (4 13) 628 -4787
ASHFIELDMA01330 ISSUED ON :41712010 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & 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:
FeeType: Date Paid: Amount:
Building 4/7/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
City of Northampton
Building Department
212 Main Street
Room 100
r r - LO10 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
G'p Map Lot - Unit
_. _
- v� \ C � 2oie OverlAyDistrict
¢EtGi St District CB District
SECTION 2 -PROPERTY OWNERSHIPLAUTHOFUZED AGENT
2.1 Owner of Recor
NameSPri ntJ Current Mail' Address:
E04= z _3
— Te�hone
Signatu
2.2 a Agent:
N 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) Check Number
This Section For Official Use 0nf
Date
Building Permit Number: 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
Side L:I _ R: LL -- R:
Rear
Building Height
Bldg. Square Footage OX 1"
Open Space Footage %
(Lot area minus bldg & paved
-kin
1 � »_
# of Parking Spaces — ----` --
Fill:
volume & Location) A. Has a Special Permit /Variance /Finding eyer been issued for /on the site?
NO 0 DONT KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Re ?istry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book Page ^ and /or Document # Nmm mmmN µ ^
B. Does the site contain a brook, body of water or wetlands? NO �" DONT KNOW 0 YES
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 NO
IF YES, describe size, type and location:
De ttliere any priiPosechanges Co or a ttlons o signs int' " for tTie property ? YES 0 NO
IF YES, describe size, type and location: a
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
s
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [0] Other [E]
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
6a II�fiCaiseaarill itiff s��
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 Wk
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize '
t my behalf, in all mialft relative to work authorized by this building permit application.
t
Signature ol Owner Date
I, L�iVaW\ C]�ErCT __ 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 g6.'d of perjury.
Print Name
F
Signature f ner /Agent Date
f
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder i Aj %LA—%A ^ � 'tC �aL�T L �--�� I d"
License Num er
Address Expiration bate
�._. >
Si a Telephone
8� Rep #stered'If+tini'e Elntbie tterneri tits tp , . .k : r �.5 ...x = Not Applicable ❑
' i C I Y1If ?I (. t ) e-i -7 �a
Company Name Registration Number
VJ tl t .i.i� l7 �t IC. ACA%
Address Expiration Date
P:o• 8b1C r AS!\ICl;D �� Telephone
C5 \
SE CTION 10- WORKER COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25 (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 ext ended to include, occuvied 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 conside a h omeowner .
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 - f 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
oft amp on r manci�s, a eneral Laws- Annotated.
Homeowner Signature
t _ r
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov /dia
-Workers' Compensation Insurance Affidavit: Builders / Contractors /Eiectricians/PIumb.ers
Applicant Information Please Print Lejibly
Name ( Business /Organization/Individual): V0 t LU P.-M D, ':I! jC_ eTTC:
Address: tom_ o . - b6 , N fii�
City /State/Zip: A6%AFfr—_lX> MP1 01330 Phone. #: 8Zfa
Are you an employer ?.Check the appropriate box: Type of project (required).
1.0 I 4z6 a employer with 4.. 10 I am a general contractor and I 6. 0 New construction
mployees (full and/or part time).* have hired the sub- contractors
2. I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeiing
ship and have no, ez-oployees These sub - contractors have. .8. 0 Demolition
working' for me in an capacity. employees and have workers'
Y P tY• $ - _. 9. Building addition
[No workers' comp. insurance _ comp..ms _
required:] 5. We are a corporation and its 10.E] Electrical repairs or additions
3.0 I d, am -a- iomeowner -d ' enal - - - -
ha — 1.0 mg repairs or additions
wsr1E -
myself [No workers' comp. right of exemption per MGL 12. FrRoof repairs
insuran required.] t P. 152, §1(4), and we have no
employees. [No workers' 13 Other
comp. insurance requinedi.}.
'Any applicant that checks box #1= must also fill out the section below showing their workers' compensation poficy information.
t Homeowners who submit this aTldavit.indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Contractors 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 th e sub - co nt r actors have empl t m ust provide their workers' comp. policy number.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
in ormaiion. .
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 required minder Section'25A of MGL 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 tfie violator. , 15e advised that a copy- of this statement maybe forwarded to the Office of
Investieations of the Dik for insurance coveraee verification
I do hereby certify,nnder the p d penalties ofp. erjury.that the information provided_above iurue_wd- correct__
Si ture: a • P:? V_ 11 Zc610 .
Phone
Offzcidl use orily Do not wr 6z this area, to be comp eied by city or town bjk&
--City or Town: Permit/License #
Issuing Authority (circle one):
1 of Health 2. Building Department 3. City/Town Clerk .4. EIectrica 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
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
regulations— The inspect ion process requires that the building department be calle 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
conjunction -to -the_ mil din g permitissued, 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 to me.
m lie
Address of work
location