36-275 (2) AE 3�csancfl tic ctla'
�a DEPnRTMEI-T OP DUILDr1\C INSPECTION'S
212 Train Strcet ' Municipal Building
Northampton, Mass. 01060
`'r`ORICER'S COQ PENSWIZON MSURANCE A17FM: .1TiI'
I S(• ASSOcIt$wS
010c: 'xlperml lice)
v.tfil a principal place ofbusinessIresidence at: ------
49� SO, M� 01333 (phone:') X13
(su-Ucirr/Stalesp)
do hereby certify, under thc.pz._ins ;md penalties of penury, h:i
(� I a-n an employer providing the following %vorkcr's colnoensZLIOP cove lge for lny
elvplovices worUng on this job.
A[GN
(Lnsir-� Conpr..) (Potic: :pircior, Dz�) -
( ) I
am a sole proprietor, general conn-actOr or homeowner (circle one) aDd have hired
the cone actors listed below wbo have the foiloviloQ worker's comoep_"zuon pokies,
0,47a 1C 0, contnci0r) Gfis-urancc Compa yil obc-, ?q=h-'C7) (-I X-trl o D iC)
i
(N:mlc of COnG-'eior) (Lns rzacc C.omoanv/Po!.M, Nu.mcrr) (-LxPu7.6on Date)
(Name of Coaa-aclo,) (Lusuranc; Companylpoliq- Number) (Expijzdoa Dalc)
(N;-'Mc of Conaw-tor) (Insurance Compatry/Policy Numbs) (Expiration Date).
(aRx3:d''EOcal s,`cC.tfnccaary w ircudr iaforma_-ioc;--� �to
{ ) I am a sole proprietor and have no One wori�ing for me.
( } I am,a home owner performing all the work myself.
NOTE:plc x cwZrt Cs .{ lc 6cmco.�vcn wtio C=GIQY D'=-"Qr=t.o do— - cs c oo c rr�au ore oa c d..<1L of
not mcrt tlia t.v �icr is u'sc{z the bocnoowoc ruida a oa the rrou s zppurtcus ibc zc ooc�xlly a d-ni to be
cixployca utw�t5c , ..,:ca Aa(GUI 52=i(5)�
�^PIiaDOO by a 6omooax fc c Lcze a pexnit cry e%idrnoc the
I-P1 of en cPloyx under tttn WorSc.elc Compom,�ti.on Act
I uodcsra.ad th.a x ooyy of thin ca.rcm.=my be for- -rded to tbo Dcp.t of In�atjic!A.&..ti'OiG_of 6--r -rot the
caves' cif coon and ttLt L-i]=m to smut bO%�r�tz&==aIDc 23A of),(OL 152 eta led to the imp=itioa of cimin!Pc—W-
'oO iag of a or up to 51300.00 and/or�Z,ypa�of up to ooc yr r end coil pm+hie is be form of.Stop Wori;Orde end a
rr>n o(S 100. a dey tP.,:5t t>x
pC7I311(Nt1ID1.7CS .
U(/ Y
Sirn.auun of Li /P e
J.'42 p.-- Lot..
'O¢�t1AMP�O
LitP of W erf4anipton
I
µd
DEPARTMENT OF BUILDI7\1G INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060 5 `
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as his/her construction supr,: .' sor. The stale defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two famity-
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 buildine 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.
t �,, 1 / 1 f11 1 nt ,mt�inrt R� -as) the
If the homeowner rlli'eJ Vlllel trades to pe Li Vrtit work`eIe Lll a. t, i.ia.viub w 5
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
f
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Suip--e''rvisor: Not(A� 1pplicablle ❑ �^
Name of License Holder: ii�N 1-NJ1 r v `- s 0 t�1 t 7 -
License Number
A 0(37 3 113(06
Addres Expiration Date
Signat Telephone
9-:Reaisfered Home:IrririiavemetitGontractor4 � ,. „, Not Applicable ❑
rtN c� ST 4.T dSSD C I Aas 1(�DSs�
Company Name Registration Num er -- - —--
1 4a. & kA, b'12� 6
Address t Expiration Date
so - (� �7�« W 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...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings fone(1) or t vo(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license, rov
p ided 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 buildine 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
r
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) Roofing
Or Doors 1`711
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [O] Other[o]
Brief Descripti n of Proposed
Work: t t;e �PiinAtla
Alteration of existing bedroom Yes X No Adding new bedroom Yes _No
Attached Narrative Renovating unfinished basement Yes _,No
Plans Attached Roll -Sheet
6a;If IVeW. house-an i oraddition to_exist><nci bousina ..carrfgtete the fof[Qw�ng:
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
6t, 1 as Owner of the subject
�? property
hereby aut ze
to act o m a a to work authorized by this building permit application.
Sig ure of Owner Date
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
hgr
and belief.
Signed un the pains and penalties of perjury. '
Print Name
f
Signa re Ow erlAgent Date
^
Section 4. ZONING All Informatic'm 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
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume-&Location)
'
A. Has a Special Perm it/Vahanco/Findi ng ever been issued for/on the site?
�~� x,� '
NO ^_�-�� DON7KNOVV �~� YES «�� '
IF YES, date issued: |
IF YES: Was the permit recorded at the Registry nfDeeds?
NO D
IF YES: enter Book
Page � and/or Dooument# /
' �
B. Does the site contain a brook, body of water orwetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to ba obtained from the Conservation Commission?
Needs tobeobtained \~�«~~� Obtained �-v_�\ Date'
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes tnorodditionsofsignsintondedfortheprope�y? YES �~� NO »,�
' �~� �~�
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,
; g�ding
un.orfiUing)over 1 ao�oria�po�ofo common p�n
th�will dimurbover 1 acre? YEG o NO ^
|F YES,then a Northampton Storm Water Management Permit from the DPW isrequired.
-- -- i Depa[tenf tse of
�Clt 0),Northampton status ofPermtt',
' BUlidln Department CdFkCUDtFy @waYPefm
r'" t
213 Main Street SeweriSepU" ila6ility
m
9 Lv 4 1 RClor 100 ater/fNeEt�va�ahihty �
Northanpto MA 01060 Two Sets of Structural glans
L phot�e,41 y $ -1240 Fax 413-587-1272 PIatIS►te Plans
OtherSpeclfy
',AFIPMATION TO 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 W office
AAffL- tA_[D 7-E Map Lot Unit.
FL� /�G�C M� Zone Overlay District.
Elm St:District CB.District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT"
2,1 Owner of R rd:
s0l 8"S �I'I�P�.�"/ei Dom' M
Name(Print) Current Mailing Address: )
Telephone^ A _l��
Signature F
2.2 utho�ized Accent:
Ve�r �anr►` +�- - �`' Gam ke. S?.
Name(Pri Q Current Mailing Address:
6!�S- -.11616
Sianature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 53 1 Gcc (a)Building Permit Fee
2. Electrical 7, 00c Construction Estimated Total Cost of
Construction from 6
3. Plumbing 3 Z� Building,Permit Fee
4. Mechanical(HVAC)
5. Fire Protection 'vim'
6. Total=0 +2+3+4+5) �ZO' Check Number
This Section For Official Use Only
Date,
Building Permit Number. _Issued:
Signature: _
Building Commissioner/Inspector of Buildings Date
File#BP-2005-0703
APPLICANT/CONTACT PERSON THAYER STREET ASSOC INC
ADDRESS/PHONE 8A COATES AVE SOUTH DEERFIELD (416)665-4018
PROPERTY LOCATION 88 MAPLE RIDGE RD-32 SPRUCE LANE
MAP 36 PARCEL 275 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid Irt J01 I/
Typeof Construction: KITCHEN RENOVATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 045159
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
1NF PRMATION 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 on
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.
88 MAPLE RIDGE RD-32 SPRUCE LANE BP-2005-0703
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mg�BIock:36-275 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-2005-0703
Project# 35-2005-0958
Est.Cost: $65420.00
Fee: $327.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THAYER STREET ASSOC INC 045159
Lot Size(sq.ft.): 35632.08 Owner: MATUSON RONALD A&
Zoning: SR Applicant: THAYER STREET ASSOC INC
AT. 88 MAPLE RIDGE RD - 32 SPRUCE LANE
Applicant Address: Phone: Insurance:
8A COATES AVE (416) 665-4018
SOUTH DEERFIELDMA01373 ISSUED ON.115105 0:00:00
TO PERFORM THE FOLLOWING WORK.-KITCHEN RENOVATION
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 115105 0:00:00 21041 $327.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
88 MAPLE RIDGE RD-32 SPRUCE LANE BP-2005-0703
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-275 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0703
Project# 35-2005-0958
Est. Cost: $65420.00
Fee: $327.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THAYER STREET ASSOC INC 045159
Lot Size(sg. ft.): 35632.08 Owner: MATUSON RONALD A&
Zoning: SR A plhAitt: THA.YER_STREEF ASS':: TN('
AT. 88 MAPLE RIDGE RD - 32 SPRUCE LANE
Applicant Address: Phone: Insurance:
8A COATES AVE 416 665-4018
SOUTH DEERFIELDMA01373 ISSUED ON.115105 0:00:00
TO PERFORM THE FOLLOWING WORK:KITCHEN RENOVATION
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: House# Foundation:
Driveway Final:
� / /-2L e _r_/Final: �� , Final: r /
Rough Frame: . 1 -
Gas: Fire Department Fireplace/Chimney:
Rough: ��� r� Oil: Insulation:
Final: /!/c S Smoke: Final:0�
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc �/�u � ✓�
� �/ Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 115105 0:00:00 21041 $327.00
212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo