23D-007 (6) -NOTE-
THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER
SOURCES AND IS NOT TO BE CONSTRUED AS AN ACCURATE
SURVEY AND IS NOT TO BE RECORDED.
T EXCEPTION SEE:
BOOK 2474 , PAGE 237
' aRCEL II
TRACT I
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TO: HERITAGE BANK FOR SAVINGS &
I HEI War �r�OKIrT A+NIS EX01. E REMISES AND BASED ON EXISTING
MONUMENTATION ALL EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON
THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES,
EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN
A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR
COMMUNITY # 250167
gr-r-r , -NOTE-
SURVEYOR: ""'ate THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY
AND DOES NOT CONSTITUTE A PROPERTY SURVEY
�`)p. A: • -MORTGAGE LOAN INSPECTION PLAT-
/0.
RANEAEI ` NORTHAMPTON, MASSACHUSETTS
o um �' PREPARED FOR
,,� 435032 HARRY W. RIDABOCK, II
l',OfESS !.; SCALE: 1 "=50 ' MARCH 26 , 1992
AND sux4E HAROLD L. EATON AND ASSOCIATES, INC.
1 . 1 REGISTERED PROFESSIONAL LAND SURVEYORS
`�^�'� 235 RUSSELL STREET - HADLEY - MASSACHUSETTS
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58 NONOTUCK ST BP-2003-0991
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D-007 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0991
Project# JS-2003-1591
Est. Cost: $30000.00
Fee: $215.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CRAIG JOHNS 049763
Lot Size(sq. ft.): 62290.80 Owner: RIDABOCK HARRY WINTON II
Zoning:URB Applicant: CRAIG JOHNS
AT: 58 NONOTUCK ST
Applicant Address: Phone: Insurance:
P 0 BOX 52 (413) 695-2757
CUMMINGTONMA01026 ISSUED ON:6/23/03 0:00:00
TO PERFORM THE FOLLOWING WORK:EXPAND 1ST & 2 D FLR BATH 11'6" X 8'6" &
mss. �
', , , ),t& = ti : t.4 lier ca. '¢01..._ c.23 o 3
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: Receipt No: Date Paid: Check No: Amount:
Building 5/22/03 0:00:00 3728 $215.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2003-0991
APPLICANT/CONTACT PERSON CRAIG JOHNS
ADDRESS/PHONE P 0 BOX 52 (413)695-2757
PROPERTY LOCATION 58 NONOTUCK ST
MAP 23D PARCEL 007 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid ,t6•1O5
Typeof Construction: EXPAND 1ST&2ND FLR BATH 11'6"X 8'6"&CONSTRUCT 15'6"X 14'8"
SUNROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 049763
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO VIATION 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
0 X:/3P/ ° 'g
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.
. _ %Depat a his _re ly
City of Northampton Status of,Permtt^ ;��,
''r' h f; \Vl fcBUUtdIng Department CurbxCut/Dyrvewa e t � x je
--"1212 Main Street Sewer/,Septtc A ariab , - �,,,, 4
Room 100 Water/Well Avattabi t y'i - . �� . 4�
JUN 2CO ortt pton, MA 01060 Two Sets of Strucctural ' ans �r� "
phone 413-587-1,240 Fax 413-58 71272 Plot%Site Plans 'R,�°^ °i ` ' , r
Tr-- Other Specif �I �, 1R+4
s
_APPLaCAT-tO-N TC 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
/ 99 / -CA Map Lot Unit
Zone Overlay District
le Elm St. District __ __ ____ CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
7
21Owne of Record:
Ar` ‘od Z✓l(y' '1 — 5-
8 AJ u ttJC_Z $ ��
O c o Z
e �g Address''I;
•
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
`/ Building Department
Lot Size GZ2 fa W5,0 e MC
Frontage 7c•3 G ,
Setbacks Front / ii. 5 ' /ff. ?S-'
Side L,:/f' R: Z L:) O R: 20 ' I�
Rear /00' /pc
9L
Building Height ze ` ay '
Bldg. Square Footage q S' — —
Open Space Footage T�J fpd`f °/o
! %l
(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 DON'T KNOW ✓ YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Doc ment #
B. Does the site contain a brook, body of water or wetlands? NO ' - i DN'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation C cmmission?
Needs to be obtained Obtained , Date Issued:__
C. Do any signs exist on the property? YES NO f
IF YES, describe size, type and location:
D. Arc there any proposed changes to or additions of signs intended for ne property ?YES _
No
IF YES, describe size, type and location: __ __
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition 71 Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg., ❑ Demolition❑ .,thew Signs [ <, Decks [ ] Siding [ ] Other [ ]
4 4 &ti- /31 fv
Brief Description of Proposed Work:Melt/teal/int 0lir% mtk 7`2,;ic t ase a„,11,f S!l^C
Alteration of existing bedroom Yes X No Adding new bedroom Yes _X No
Attached Narrative ❑ Renovating unfinished basement Yes ,X No
Plans Attached Roll ❑ . Sheet D
6a. If'New. hsouse an"d"or addition to existin: housin_ 'corn slete'the following:
a. Use of building : One Family )` Two Family__-_-- Other
b. Number of rooms in each farnily unit: Number of Bathrooms 2-
c. Is there a garage attached? NQ
r . n
d Proposed Square footage of new construction. zg9's Dimensions ?X 2-7 X /4/57
e. Number of stories? gortt otYwr .(7) ftl+ti�'D>Gv4t)
f. Method of heating? to/4d kvf ai✓` Fireplaces or Woodstoves / Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction 14l01g1 011.40...
i. Is construction within 100 ft. of wetlands? Yes d( No. Is construction within 100 yr. floodplain Yes X No
.,Gj. Depth of basement or cellar floor below finished grade
k. Wig' building conform to the Building and Zoning regulations? ✓ Yes -_- _ No .
I. Septic Tank City Sewer / Private well City water Supply- ir
SECTION 7a -OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, __ _ , as Owner of the subject property
hereby authorize to ac; on
my beLe '. in all matters relative to work authorized by th s _;uilding permit application.
Signature of Owner Date
1, _ , as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowlecge and belief.
Signed ender the pains and penalties of perjury.
---- ------------ ---------
Signature of Owner/Agent Date
SECTION 8 -.CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: r Not Applicable ❑
Name of License Holder : �✓ue�/ (7 NM $ _0 G/7 3
License Number
pso ' 5 Z' CdPrig ,/`Tu• 0/D2a /D/ 12vvY -- -
A•: ess Expiration Date
695'1 Z 7 s -
/�. Telephone
.9:Reisfeied Hom `imige'met Contractor'` „VMZf,,, n„ Not Applicable ❑
Company Name Registration Number
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 ❑
11:%3 HomeOwnenExemption
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 fir 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 _
`� � ,� (i ifu 0f ar#li�nnpfon t
- ..1t B f��asaachrtsrtta `' ,_
�.,- DEPARTMENT OP BUILDING INSPECTIONS \\\ �` __ E
212 Mein Street • Municipal Building
—F1—.�
1 Iding
Northampton, Mass. 01060 OW''
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
1 r�! S
(lie nsec/l:rrm ttce)
■:rith a principal place of business/residence at:
43-_%Pw
-_P•ge+? au_ rphoncj-)1/1 65=2 7S7
(strce.t/city/stab -Lip)
do hereby certify, under the pains and penalties of perjury, that
(
I am an employer providing the followlnt, ':-.or�-,er's compensation coverage [or In}'
employees working on this job:
- (Inrnrarice (_:ompany) (Pokey Number) (Expimtfon Date)
(S. I am a sole proprietor, general contractor or homeowner (circle one) and have lured
the contractors listed below who have the following worker's compensation policies:
(Marie of Contractor)
(Insunnc;, Company/Policy Numbcr) (Expiration Date)
(Name of Contractor) (nsurancc Company/Policy Number) (Expiraioa Date)
(Name of Contractor) (Insurance Company/Policy Number) (ENpirataoa Date)
----------------------
(Name of Contractor) (Insurance Como<_t;yrPolicy Number) (Expiration Date)
(rttadi 6:.( i«al sl;:ct i f::,,c:vr:to iroiudz it Demerit a:poataininr to Ali o_<:codr::•.)
( ) I mn a sole proprietor and have no one '.vorku]t; for toe.
( ) I am a home owner performing all the -work-. myself
no rE:plc,„tr A„-„c that n i]c harrastizr-n u;nO c:nploy rr,zos to ds rr,u-.tcnancc,cc-crnt-,:cctoo or Itpair no :.:G«c1!1.^.i-,c:
not more th n threo units in wrindt ti-,e ti-,e Ia, rose rn:cw or rxr Li.: ;,c;r-is apurtec:ri thcccto cot riot[cxrdlly CO_I:deter::3 h:
trnployca unocs tlr WOri;cCr OCT;c.—s:Ai On Act(GLI52,L1 1(5)),:_r:pl:o:-ticn by a hotimstnrt torn licmnc cc pc-ran::::e v r: ;n c Ili.:
legal ctam;of an�loyor under tbo Workcra Cornpornation Act_
I undcntand that a copy of t}ii ctatcn;mt may bo fotwrc dod to Lb',mpanarnt of Industrial A.:id ni-?()Moo of I,rcrc.rc o for tho
coverage vcrificatioo aril that t failurc to otcuoc covcrago undo-seeiion 25A of MOI,152 can lead to the imposition of criminal peea11ic
000zuti ng of a fire of up to S1,500.00 anot'or i.rpris tnnc;it of up to one}Tar and civil pcnzRtia in the form of a Stop Work Order and a
firm of 5100.00 a thy ig in t err
For dcpartnant al u.o coyly
u// Ql Permit i itllnbcr
7` Map;, Lot
--4 Sittu .✓.g LienscrJPcrnlictcc 1)�"e
littie... ...,
tY 4�
•
NAMP
tit OQ�, yTO
'`� Crzt of ortlpunipton —. r/
;4V Ifilassaciptsctts
DEPARTMENT OF BUILDING INSPECTIONS � =: =i= i
INSPECTOR 212 Main Street • Municipal Building
�y l,s
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as Li /her construction sups: ,'isor. 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 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 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
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
1-xi3b14,7 �
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58 NONOTUCK ST BP-2003-0991
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D-007 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0991
Project# JS-2003-1591
Est.Cost: $30000.00
Fee: $110.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CRAIG JOHNS 049763
Lot Size(sq. ft.): 62290.80 Owner: RIDABOCK HARRY WINTON II
Zonin':T,3 RP Applicant: CRAIG JOHNS
AT: 58 NONOTUCK ST
Applicant Address: Phone: Insurance:
P 0 BOX 52 (413) 695-2757
CUMMINGTONMA01026 ISSUED ON:5/22/03 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 11'6" X 8'6" BATHROOM ADDITION
(EXPAND 1ST FLR BATH & ADD 2ND FLR BATH)
POST THIS CARL) 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 VIOL N OF
ANY OF ITS RULES AND REGULATIONS. _
Certificate of Occupancy Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 5/22/03 0:00:00 3728 $110.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2003-0991
APPLICANT/CONTACT PERSON CRAIG JOHNS
ADDRESS/PHONE P 0 BOX 52 (413)695-2757
PROPERTY LOCATION 58 NONOTUCK ST
MAP 23D PARCEL 007 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid ��a1 %in /AP
Typeof Construction: CONSTRUCT 11'6"X 8'6"BATHROOM ADDITION(EXPAND 1ST FLR BATH&ADD
2ND FLR BATH)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 049763
3 sets of Plans/Plot Plan
THE LLOWING 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 Co ion
2. .0
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.
-- -- �i ' , �De!a f 360 e,RI kr. � ;
. -City of Northampton S.atus f Per v ,--,•,:i-.,-:';', t Aq4 t '
Building Department Curb Cut/D g a 1 �:
- 212 Main Street Sewer/Sep to ---„;� s
Room 100 Water/Well Avai1ab 11,,.. .4.4:::-,.....-2.11-4.1. - «
MA`( — s ` Northampton, MA 01060 Twol,Sets,o f'Str c ural ' q
r~n�
phone 413-587-1240 Fax 413-587-1272 Pint/Site Plan
Y Y4. i•
Other�Spectfy fi� Iy .; `
-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:
Fy Map 3 Lot Unit --
O /�o tJ a v vk
1��L r-S • 0 / 06
Zone i Overlay District
Elm St. District CE District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1. Owner of Record:
14,- c, -� 0 , .a; dy . .,Srr g ,k)b�-�
. 5
[Jam (F r t) ',: aing Address:
l'? btoZ•
`e.ephnne
,g atu e
2.2 Authorized Agent:
^Janie 0 rint) Current Marling Address:
cf,ign t .re elephnri,
I
1 SECTION 3 - ESTIMATED CONSTRUCTION COSTS 1
--
I stern Estimated Cost (Dollars) io 'o4 Official Use Only
coq feted by p=rrn:l arch-ant
eli iirrg _..o S---' D — (a) Building Permit Fee
rl ,timated Total Cost of
/ 2 COr Construction from (6)
T
1 3 Pl rnbir g% � Building Permit Fee
1
,,,,,,(.rornic:. (IiVAP)
5 Fire Protection
i (a ' aryl :- (1 -+ 2 + 3 + 4 + 5) ,30 OOO Check Number 3#7694;
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
--------------------
L_ Building Commissioner/Inspector of Buildings Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
� n
Lot Size acre-q 0,
Frontage 115: J
Setbacks Front /Z o• /70' �4°
Side L: 2 S'!R: /SS' L: 20 z R:
Rear Z2S_' 22S ■
Building Height
20 t
Bldg. Square Footage % ( 2
Open Space Footage
(Lot area minus bldg&paved 540
parking) v
#of Parking Spaces /VA
Fill:
(volume&Location)
A. Has avSpecial Permit/Variance/Finding ever been issued for/on the site?
NO !� DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document It
B. Does the site contain a brook, body of water or wetlands? NO X DON'T KNOW
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 X
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
SECTION 5- DESCRIPTIONtOF.PROPOSED WORK(check all applicable)
New House ❑ Addition Replace ent Windows Alteration(s) ❑ Roofing ❑
Or Doors �l
Accessory Bldg. ❑ Demolitionb7 New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: / 6A rOorM S I S oft2 I rI r► l r d
Alteration of existing bedroom Yes x No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes (\ No
Plans Attached Roll ❑ - Sheet`i
saAPNew'hotas"e:end or"'atldition to existing housing, complete the ellowing:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit:_ Number of Bathrooms 1
c. Is there a garage attached?
„ i it
d. Proposed Square footage of new construction. Dimensions-,_// 6 K g -6
e. Number of stories?
f. Method of heating? - I)A AtC- Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes X No. Is construction within 100 yr. floodplain Yes X 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, /� °)\/. .r.-43,6crr,e , as Owner of the subject property
hereby authori e (ur to act on
my behalf, in all matters re tive to WO'k authorized by this. 'ouilding permit application.
/4 X) e_4_ 7/0
Signatur of Owner Date
I, _ , 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 and penalties of perjury.
--- —---------------------------
Print Name
Signature of Owner/Agent Date
•
SECTION 8.-.CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : � _( • J d1")N1 S -_ l/ i./4 " "' 3
License Number
a 0 C5X . -ice, ►lqA_ 7olr
Address Expiration Tate
e
4c:)3 - Z ?37
Signat e / Telephone
;9: R :iS~•red:om`e lmpr4vement Contractor:k ;;_' E . _, m su Not Applicable ❑
Company Name Registration Number
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 ❑
tig�. °Rome caner#< %em Inon
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 witl, reference to Chapter 152 (Workers' Compensation) and Chapter 153 ;l iability 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 ___
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iii AARC17.Ii?NT OP i?UIIDIN�G INSI'i`.CI'IONS
`?.12 Main Street • Municipal I3uilcling t(
Northampton, Mass. 01060 �Z_r
W'ORKER'S CO:A1PENSATION INSURANCE AFFIDAVII
I, (re,j (�. f_tr/ s
\','1ri1 a pii11cipal t?IFaci' r)i bush' ;S/1t';',(ienc ' 3t.
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1 3111 all CI111)i0)'Ci t t(.. tll; it)ilO.,'ii O`...0; :, COP i1 (, .'L 1 -
Cll71)loycct; Pool};llli on this
(Insura IG Cotnhow) (Policy Number)
1261 1 SOIC 1?I-01)11CiO1, , (!110rdl C rulruCto: ;C homeowner (c::ole one 37C Love hiCCU
the coittrc ctors lIstCC DC:-.low ::o have die iollowthr worker's COI"?i)'CI1S :C)i:
(Nero: of Contractcrl n_, ..t„c Corror,:,jtI'olicf Nt�,:rc;� �,I . Uatcj
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(>4., I 1111 -c. :hr t'IUj?; �Ui ._.,1 .'1<:V., 0 ) uric, for
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the: rt'-a �aat c: - (Cif.!5?r.a l O t) f,' _._._ :y a 110n1 o.t-rr Or I, :_r c I?c......
Icgal ctato;of to o.ntployoc undo t`..o Wcv4-a't C'o;r{mritran Act
I undcrstand tllit a co qty of thi,c tatc:o r:may t o fvttia,valo:t tot e:Gctxir tz,c:,t of I>daan:J Acd:.c sr O11ic-n 01 1,0111:n c fot U,c
covc`i-gr VC-ificatic t zl.f,fi that fedut-n to 5t-tn–t curt ao or r seGicn 25A of 001.152 can Ic_d to the itn{>ositicc,,of aa:. _I Ixttrh:u
ooanuting of a fir_of up to$I.ScO(uO eal r i'::nti�.,:r-:::of up to tn..1 civil pervP.icr w fr fcmn of o St,°,,1V�-1-.0 -r tr,:1
f wofSl(T .X.) day ac�irat ode_
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DEPARTMENT OF BUILDING INSPECTIONS /;'
INSPECTOR 212 Main Street • Municipal Building
1y S,,ly
Northampton, MA 01060 .
el
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction sup:: :isor. 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 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 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
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
MAY — 2 , 2003
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