17A-299 r [4 1 (1cReesCD
4i R 042rn 1 " Ca .. I r464
" faster Suite ta
a.
Hall Bath:
\ `` -, Re piece tlAc gliders
Bedroom: Remove closet wall — Sae flour
Tile floor 1 'kerrv�3e tub unit
° Replace fogged glidng - rtdea, E 1 A,, ,,, install shower stall In to r a rtu shower surround
Create single -door closet, °x.5' ' f& k Neiv anity_ toilet, r€ d cab Me rtnilet rr d cab
Frame in and she etrock existing T shower stall A New ' vanity_ counter double sinks
:. :lffnset do orvva y um New shoower doors
0 (-7---4,. , , ,, i,a 4 ) ° /
� � Other ; 0
`� e � re k is nit in first floor r .
r ._— Install � sl er dr r in first floor r�r ca
� f. Install doors on new .aundrynook li — p ,' f Build e steps at sur rc =c� r doors
fi ;, install wood handrail on sunroorn stairs
w
Second Floor:
dust railings as needed. install pie i - ass filler P Not Included:
, raid smoke detection as needed for code
Replace all doors with paneled doors — #`, Changes to heatin h oling
Reccessed lighting throughout
Finish paintir (we prime onl i
MINN
1
Ai
IMMO
AISNE! 5 i ro, 4k ( ( 1) ezikRev,3 it
tom, n II II a Jo 5 c(3 � -r,1, F L, clArcc. ,,� p °5� w , �N ! //e (T 6 - O ^l �
i v io tzo? a
City of Northampton
'`g • 0 Massachusetts
f * ag e i+
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building vy, i;~
\, " w Northampton, MA 01060 yy
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 c onstructs more than one home in a two-
year period shall not be considered a home owner."
The building dep. ment for the City of Northampton wants an • erson(s) who seek to use the home
owner exemption, act as their own construction superviso , to be aware that by doing so you
become responsib . for compliance with state buildi • codes and regulations. The inspection
process requires that t - building department be calle. o inspect work at various stages, which include
foundation /footinqs (b- • re backfill), sonotube es (before pour), a rough building inspection
(before work is conceale• , insulation inspec '•n (if required) and a final building inspection.
The building department requ -s these inspect•ns before the work is concealed, failure to secure
these inspections can result i failure to o stain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades •, pev orm work (electrical, plumbing & gas) the homeowner will be
responsible to make sure that the trad - ired 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
understand the above.
(Home owner /resident's s' nature requesting exemption)
I will call to schedule all requir d building inspections necessary for the building permit issued to me.
Date
Address of work location
The Commonwealth of Massachusetts
Department of Industrial Accidents
a
� Office of Investigations `
.= a 600 Washington Street
"ice ,
.� _ Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): SCe r e n 4 'no f re y
Address: ) S Oecr s n l 5
City /State /Zip: p/4 (A eR-c /J. 1 d 1070 Phone #: L i/ 3 6 7'1- 2088
Are you an employer? Check the appropriate box: Type of project (required):
1.0 I am a employer with 4. 0 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. gi Remodeling
ship and have no employees These sub - contractors have 8. 0 Demolition
for me in any capacity. employees and have workers'
working Y p Y 9. (7 Building addition
[No workers' comp. insurance comp. msurance.
required.] 5. 11 We are a corporation and its 10.2 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.K Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance 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.
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 the sub - contractors have employees, 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:
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 under 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 the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature 5 Date: 6 — / — / .2-
Phone #: ( 1i 7 6 3 y - 808.
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town: Permit/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 I
8.1 Licensed Construction Supervisor: ^ Not Applicable ❑
T
Name of License Holder: Sefertc, I b -' y 7g90y
License Number
5 ' efeu.5„, t 51 l pla,ti. -6 /14 81070 - 3-31-013
Address Expiration Date
_ Vf3 3Y -8oae
Signature Telephone
,-i.� ' i , e. -.. Ct Zr - i 4 Not A
9.Req "is `ter. "ed liorrie.l "mpcovement Corittactar.� r : r � ., . ,:� Applicable ❑
See'cvt . Mrrey's S4 1 a w►a•. der- f - Corotractro /Li/ 9S0
Company Name Registration Number
I S ' j/ectsk.. t S7' pid'), /d / 0i 07o 3- -Oly
Address l Expiration Date
Telephone 1 03 - 4 7'f -d'
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG 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 A No ❑
1 . -- {ome .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. A person who constructs more than one home in a two - ye period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form a eptable to the Building Official, that he /she shall be
responsible for all such work performed under the building pe it.
As acting Construction Supervi- i r your presence on the job s' - will be required from time to time, during and upon
completion of the work for which t ''s permit is issued.
Also be advised that with reference • Chapter 152 (Wor, rs' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting i Death) of the . sachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you unde his permit
The undersigned "homeowner" certifies d as .mes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local : e . ng Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House n Addition ❑ Replacement Windows Alteration(s) Roofing I l
Or Doors XI
Accessory Bldg. n Demolition New Signs [D] Decks [0 Siding [D] Other [D]
Brief Description of Proposed
Work: re mode. I 2 4'X;9 J ( 4 fheoosls,
Alteration of existing bedroom Yes x No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll - Sheet
sa If<New. ouse and ro a`ddit on..to existinG hou isis ng,- complete therfaHowinq:
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--;
1, Mvt ,ri ?1NC't4o.“ , as Owner of the subject
property
hereby authorize SC d01 1
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date` .. — 'L,
1 - re r e vi ck Cif C y , as Owner/ uthorize
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my nowledge
and belief.
Signed under the pains and penalties of perjury .
SeY E n o . ` - j r it e
Print Name
6 — / — -
Signature of Own- Agent Date
I HO C hC-1
Section 4. ZONING All Information Must Be Completeerhermit Can Be Denied Due To Incomplete Information
Existing Proposed Required by l ioning
This column to be filletl\inAy titt,
/14.? Chet i Building Department
r-- ,
■ ,
Lot Size
--, ; . .,...... _. . , ,.........
,
Frontage ,
Setbacks Front
....._....___ „............_ , ,
— ;
Side L:',. ' R: L:',_ R:
Rear i I
1 1 ,
Building Height ,-----,
. , .
Bldg. Square Footage 1 i
Open Space Footage
(Lot area minus bldg & paved , .
'
parking)
i 1 i ! ■
# of Parking Spaces
Fill:' 1
(volume & Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book : .
, Page: and/or Document #:
B. Does the site contain a brook, body of water or wetlands? NO 4 0." DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
, Date Issued:
C. Do any signs exist on the property? YES 0 NO ig
IF YES, describe size, type and location: 1 '
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO cz
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 *
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Departmeoltuse onty
[ � a-� ,, ___ y of Northampton St of t e r m �t TM � 's `
- B ilding Department G'rb4OutfRriveway ?ermlt - i
2 12 Main Street Sewer/ eta taAvailattil �� �
5 2012 1 Room 100 VVateMel A�uaila rt ' r.�� ,
No hampton, MA 01060 Twcr Se s ofiStrucfiuralP a X s " _
DEPT. OF BULL,
hane`113- 87 -1240 Fax 413 -587 -1272 P� e_ _. ,"
NORTHAMP. 1A OTG"
O t erS Z s
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: ,
This section x tie completed by office �,
�Ma , u Lot; � � ��"�"" �Unit € � x
IS' H,` / /c eS*
/IA C 4 ' � } , rla
I t7 (� a Vl C Q �ZOtl �h� � - ' OVey� District ,..K°aa' +..: ?.x ''�-� � ^x K''' s, :
Erin St,,
D �s CB District
SECTION ` 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
N1AtLt.6 11.$c1 .1 tLte %51 liks'u.CitElt fla• ft,oltelLt, I.4 ojoct.
Name (Print) Current Mailing Address:
A t Telephone
Signature
2.2 Authorized Agent:
Serevia Torrey / rg P /eu Sf f /4i'n 'eld MA
Name (Print) Current Mailing Address:
y i 3- 6 3 y- gog,3'
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Offic Use Only ,
completed by permit applicant ,
1. Building e I 000 (a) Building Permit Fee `
2. Electrical (b) Est Total Cost of
. ) O0 0 Construction from (6)
3. Plumbing (-1 ®Uv . Building Permit Fee
1
4. Mechanical (HVAC) .
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 34, 000 Check Number
This Section For Official Use Only
' Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -1078
APPLICANT /CONTACT PERSON SERENA TORRY
ADDRESS/PHONE 158 PLEASANT ST PLAINFIELD (413) 634 -8088
PROPERTY LOCATION 157 HILLCREST DR
MAP 17A PARCEL 299 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ��CF 1 y
Fee Paid // !!
Typeof Construction: REMODEL 2 BATHROOMS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 078904
3 sets of Plans l Plot Plan
HE FO ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I ATION PRESENTED:
Appr oved 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
D 'tin lay
l
Signature of Building 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.
157 HILLCREST DR BP- 2012 -1078
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 299 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -1078
Project # JS- 2012- 001860
Est. Cost: $34000.00
Fee: $204.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SERENA TORRY 078904
Lot Size(sq. ft.): 22128.48 Owner: RACHELLE MARLENE
Zoning: URA(100)/ Applicant: SERENA TORRY
AT: 157 HILLCREST DR
Applicant Address: Phone: Insurance:
158 PLEASANT ST (413) 634 -8088
PLAINFIELDMA01070 ISSUED ON:6/7/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL 2 BATHROOMS
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 6/7/2012 0:00:00 $204.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner