29-045 5.
7
2 i 2 m:,"m S Lr=,, E L:-ding
M G 10 G
-ENIJ
H DAI E A 01 E R E X 4.PT
The State 0--fWassachuse-tts allows the homeowner the righat under 780(---MR 108,3.-,,r to
aCl a5 iii e-Cop -:SO r_ T h- star--- -'afines "Homeow-ner" as, '-erson(
tends to be, a one ortwo family
-L-
d�w--7'1.ng, attached stru=—,res accessory ILO such us e and./or farm s--,LCL res.
person who constructs more than one home I'- a two-year period shall not be considered a
home owner,-
The b u-,-ldi-a-z-d.e7aaitnaent- for the C i-Ly of N-Lorth�--npton V'-ants any pe.-SOE(S) 'Whi 0 seek to
as I-
use lie home OVmer ex-.=Mptlon' to aat - Llie:l
that by doing so you become responsible for compliance with state building codes
and reT2afions. The inspe--'Ion process-requir-es that the building depar tm- ent be called
to iaispe--, work at various stages, -which include found2tion/footinzs (before backTUD.
so-notube holes (before r)our). a rough buRding ins-oection:(before work is
co-r�cealed. iiis4im-ttion in&iaectian (if reguired-)an-d-a-finall-huRding-i=ectien- ?"he
b ding deparanent requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occur)ancV
unt-31--the-worik C-be-Jnsz).ectzd--
L-7the homeowner hires other trades to perform work (electrical, plumbing&gas) the
homeo-wnrer-will be responsible to mane sure thatt-the trades hired secure their P roper
permits LZ conjunction to the building permit issued, and that they get their required
inspections.Failure ol"the individual trades to secure the permits and inspections as
required h permits inspections ar.
e =ez-1 ca-zi RIE-ILAY the proje-I unril such time as the proper per ts and,
made
TI 1--derstand the above_
(Home owner/resident's signature requesting exemption)
I wi-71- call to schedule all required buildL-1-C,inspect ions necessary for the building Pe='t
Issued to rie.
Date
Address.of-wc-work-------
location
s Levrrr-t,�rt2rit i!s' 1nw�isii I'd_lCCid-elws
a _
-. O ce of Invest.,rations
600 ff cashm t n Street
Boston, 14 0 111
a wyvn.rnnss.go v/ditr
Workers' Compensation Insurance Affidavit: Builders/Contra,--tors/Electricians/'Plumbers
A=)rlica.nt Information 'lease Print LeQibls-
Name (Business;'OrEanizationi'Individual): ��/�lr 5 ��5 JE5 6t,1 S —
address: 31 5 e4va
City/State/Zip: Act" -a 0/0/o3_5--Phone #:
Are you an employer? Check the appropriate box: Type of project(required):
j 1 I am a employer'with 4. ❑ I am a general contractor and I
—� J 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
?.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [ Remodeling
t
These sub-contractors have S. 17 Demolition
ship and have no employees �.
working for me in any capacity. employees and have workers' I 9 [❑ Building addition
[No workers' comp. insurance comp. insurance.-
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
d.❑ I am officers homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] c. 152, §1(4), and we have no
employees. [No workers' 13.F1 Other
comp, insurance required.]
*Any applicant that checks box,=1 must also fill out the section below showing their workers'compensation policy information.
Ho meowners who submit this affidavit indicatin;they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Conuactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
emplovees- 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: (9 12r)AS__ L x-015
Policv F or Self-ins. Lic. n: W C, 240 — S Ito Expiration Date: 6 - 8 .- o?
Job Site Address: Z3 I 01� of I'SIj.o t,t� Ate# 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 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DI_A for insurance coverage verification.
I do hereby certi na.ties_ofperjuiy-that-the information provided above is trace and correct
Signature: Dater
Phone
--0ffciraLzcse_only__Do_noLrvtite_inlhis_area to b�completed ._city or town off_rcial
City or Town: /?JGi�/��a�.�%'� Permit/License ��' 21_ ---
Issuing Authority (crrc /
1. Board of Health . Building Departme t 3. Cit,;!Town Clerk 4. Electrical Inspector �. Plumbing Inspector
i,
6. Other l
Ph
Contact Person: one =: ��
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: �tE 1'N't'iN U ��' Z
License Number
o
Address Expiration Date
Sigag-Efure Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
10 a Y 7�
Company Name C Registration Number
F5 az z
Addre s /� / / Expiration Date
Telephone-/�J� 'Z 5-6 '14a
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 buil ing 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. 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) � Roofing
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [o] Other[Ell
Brief Description of Proposed Q
Work: R+--t4 o u4*7 — 1 111 6 ez�h1 S IMF FDUT{��I N[
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 Other
b. Number of rooms in each family unit: Number of Bathrooms _
c. Is there a garage attached?1_ a
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 W bOD
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 j ",o U �x
to act on my behalf,Jp all matters lativ,�to work authorized by his building permit application.
Signature of Owner Date
U L as GA30r#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 Nagofo
ZZ—G
Signat r/Agent Date
x
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: R: L:. ..._,. R::
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 DONT KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT 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 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
QN
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
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
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans'
OtherrSy
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLIP, 'AONI=OR'"TWO FAMILY DWELLING
�,: ^ ^nr5o
SECTION 1 -SITE INFORMATION j I `�` vu
This section to be completed by office
1.1 Property Address:
l
-� /� !�'/CJ( t_,S" Map I Q l.o€ S Unit
1dr4EE.
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nam rint) ' Current Mailing Address:/ t
'� 4/ - �8 —320
Telephone
Signature
2.2 Authorized Agent:
U L i �� s Pl a za �d , rna
Name(Pri Current Mailing Address:
X13 -- 2�6-16 O6
Sign re 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 Only
Date
Building Permit Number: Issued:
Signature:
t
Building Commissioner/Inspector oBw mgs - ate
File#BP-2008-0713
APPLICANT/CONTACT PERSON STEPHEN J PROULX
ADDRESS/PHONE 31 CAMPUS PLAZA RD HADLEY (413)256-1606
PROPERTY LOCATION 23 PIONEER KNOLLS
MAP 29 PARCEL 045 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
BuildiniZ Permit Filled out 00 dj
Fee Paid
Typeof Construction: RENOVATE EXISTING BATHROOM(SAME FOOTPRINT_
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 093142
sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOIjd41ATION PRESENTED:
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
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.
BP-2008-0713
G s#: 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)
Cmcsorv: BUILDING PERMIT
Permit# BP-2008-0713
Project# JS-2008-001 1 1 0
Est. Cost: $5000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEPHEN J PROULX 093142
Lot Sizc(sq. ft.): 11979.00 Owner: ELLERBROOK RAY A&WENDY J
Zoning: URA Applicant: STEPHEN J PROULX
AT. 23 PIONEER KNOLLS
Applicant Address: Phone: Insurance:
31 CAMPUS PLAZA RD (413) 256-1606 WC
HADLEYMA01035 ISSUED ON:212812008 0:00:00
TO PERFORM THE FOLLOWING WORK.-RENOVATE EXISTING BATHROOM (SAME
FOOTPRINT)
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:
BUildin" 2/28/2008 0:00:00 $50.009527
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo