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212 Main- SIrtttt Et Municipal Euilding ��\ ` /f/
INSPECTCP .'
Northampton, MA 01060 .
HOME, OWNER L EM -PTION ACKNOWLEDGEMENT
e State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his /her construction sup. ° : :sor. 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 any per sons) 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 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
can-cealed -1. in- sulatian- inspection (if reauired) and_afn buHrdinainspection. 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
permits 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 to me.
Date
Address of work
location
i . The Commonwealth of Massachusetts
Department of Industr al Accidents
"= --° - F es- - = Office of Investigations •
. 600 Washinaion Street
c K` Boston, M 4 02111
% www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anolicant Information Please Print Lecribly
Name ( Easiness /Organization/Individual):
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: I Type of project (required):
4. I am a r eneral contractor and I
L Q I am a employer with 6. ❑ New construction
employees (full and/or part-time)_* have hired the sub-contactors
I 2. I am a sole proprietor or partner- listed on the attached sheet i i ❑ RemodeJT"Q
ship and have no employees These sub - contractors have g. D Demolition
_, employees and have worbars' + 1
wol nQ for me in any capacity. y { 9. 0 Building addition I
I rlvn .,rk.ers' com comp. mc.?rance.* I I
w . _ "'� """ 10. E1ertLica_ rep airs or additions
required_] 5. ❑ We are a corporation and its ❑ T
3. [] I am a homeowner doing all work
officers have exercised their 11.0 Pltmabms repairs or additions
myself. [No workers' comp.
insurance rift of exemption per MGL 12.� Roof repairs insurance refitted ] t c. 152, § 1(4), and we have no
employees. E.N. workers' 1' Offer •
comp. insurance required.]
- - ----*X y applicant mat caecxs oox oI must aso nit out the section oe :ow snowing 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.
:Contractors that check this box =stomached an additional sheet showing the name of the sub- contractors and state whether or not those entities have
employees. If the sub -cone ctors.have employers, they must provide their workers' comp. policy number.
I am 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:
Joh Site Address: Ciry,'State/Zip: .
Attach a copy of the workers' compensation policy declaration page (showing the policy number and e_apiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can Iead to the imposition of criminal penalties of a
fine up to S1,500.00 author one -year imprisonment, as well as civil penalties in the form of 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 Office of
Investigations of the DLk for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
_ — maft - Date:
Phone '4:
fl Ori ciai use only- �'o not , write in the area, to be completed by city ur town officiaL
City or Tow _Per-mit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone .. -:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ,J4 v C L ✓k' Cd r
License Number
� U 5.1-i >% F' e -c r_ N, Fc c e e_ O I 00- // 6 Z c i o
Address ' , Expiration Date
`/'3 se C V y�
Signature - - Telephone
9. Registered Home Improvement Contractor dt ` //3et z 3 Not Applicable ❑
. sc C 0 a GCS I Y',3c 2-3
Compan Name Registration Number
It 5 , -r- t) L-Af -- v -
Address Expiration Date
e
t'L a It �..: c NI F}
0/ C (� L
Telephone se d- 93Y
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 ❑
11. - Home Owner Exemption
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. . erson 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 he
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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing
Or Doors E
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [Q Siding [p] Other [
Brief Description of Proposed `J 1 C Ac C 5 D I b X I L P
Work: FA A-Me-
Alteration of existing bedroom Yes —` No Adding new bedroom Yes No
Attached Narrative .. Renovating unfinished basement Yes — No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family X. Other .`V'
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
i I
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
I, , as Owner of the subject
property
hereby autho ze. --
to act on rr�behalf,'in all matters relafiVe -work authorized by this building permit application.
Signature of Owt `" " Date S Z: , crc
I, 9 \ D• v, p C R- , as Owner /Authorized
Agent hereby deC1a that he Slate r+ nts and information on the foregoing application are true and accurate, to the best of my knowledge
and belies "
Signed under the and pe•= ies o •erjury.
Print Name "C �••.. "�.��
Signature of OwneiiAcent- � - " "'�� Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
U jZ (3 This column to be filled in by
Building Department
Lot size C Z o`Z
Frontage
Setbacks Front
Side
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO C) DONT KNOW Q YES Q
IF YES, date issued: —
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW YES Q
IF YES: enter Book _ Page — and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained — Q ___., Date Issued:—
C. Do any signs exist on the property? YES NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q 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.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
VI M I 2 1 LO MA 01060 Two Sets of Structural Plans
phone 413-5 \37-1240 Fax 413 Plot/Site Plans
Other Specify
-J
.APPLICAT15N 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:
N (..4 ST Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: D C_LrIAK
IL 514EFF tELD LPI.J r
Name (Print) c
Current Mailing Address: L elzE cz A/NA el 66;1
Telephone 1 3 s 3it .,, 7
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 permit applicant
1 Building `t' `leo ( 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) 1 9 C4) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector OfBliildings Date
File # BP- 2010 -1043
APPLICANT /CONTACT PERSON CLARK DAVID M
ADDRESS/PHONE 16 SHEFFIELD LANE FLORENCE (413) 586 -4347 0
PROPERTY LOCATION 59 NONOTUCK ST
MAP 23D PARCEL 199 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out Odk�
Fee Paid
Typeof Construction: CONSTRUCT 10 X 14 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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
A pproved 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
'-(5 _C 0
Signature of Building Offi ial 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.
a a BP- 2010 -1043
GIS #: COMMONWEALTH OF MASSACHUSETTS
v
ICI 23D 104 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 -1043
Project # JS- 2010- 001541
Est. Cost: $900.00
Fee: $28.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID CLARK 000635
Lot Size(sq. ft.): 12022.56 Owner: CLARK DAVID M
Zoning: URB(100)/ Applicant: CLARK DAVID M
AT: 59 NONOTUCK ST
Applicant Address: Phone: Insurance:
16 SHEFFIELD LANE (413) 586 -4347 0
FLORENCEMA01062 ISSUED ON:6/1/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: CONSTRUCT 10 X 14 SHED
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 6/1/2010 0:00:00 $28.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo