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Deed Ref: Book/-5'81L Pg. 03 Plan Ref.: Book Pg. /0/
THIS PLAN • • MORTGAGE PURPOSES ONLY . IS NOT , PROPERTY
BAYSTATE ENVIRONMENTAL DATE : Z -Zo -qZ_
CONSULTANTS, INC.
296 North Main Street,
SCALE
East Longmeadow, MA 01028
JOB # 9Z- 0/00-31
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DEPARTMENT OF BUILDI]sTG INSPECTIONS /=
INSPECTOR '212 Main Street • Municipal Building S,
Northwnpton, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction sups.: sor. T he state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be,a one or ttivo fumi�
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 eegulations. 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
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20 r ct�.c.Oy /�r� —�_
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DEPARTMEIJT OP DUILOD710 INSPECTIOI.'s
j 212 Main Strcct ' Municipal Building —
1,lorthnmpton, Mass. 01060
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WORICER'S CO'NfPENSA'nO.N CqSURA-N CT- AI=, AAFj-J'
� (licclisxJfxrm�it'cc)
%with a ptZncipal place of businessfresidenc.e at: ------ -
J
`` 1ro eo7I 9
7' ��✓,.r / �`
(phone-'!) -, 3
(sa�t/ci ty/staich p)
do hereby certif-, under thc.p?-u s and penalties of per3w-y, :hat
( I am an employer providing vie follo%ving�workcr's coin ocnsado, coverage for Inv
taiplovees worlang on diis job:
' I
i\, sari V VC G Of?qO 010 2-00 q._. y -
(tsn>_ran= Coar,�,) (PaLic- Nu r) (E-xpim on D2j^.)
O I am a sole proprretor, general contractor or homeov.Der (c cie orne) aDd have hilt(i
the contractors listed below who have the 'tokl ving worker's policies:.
(i+Il1D: Oi C0 r^CiOr) (In urancx. CoInpan)-Pt obCi ��r12t11LCT) – (Y_ti)IiJL•Qn I�atc)
(Name of Coomclor) (lns-uranc- Comoanyi?oUcy Numn cr) (Expim ion Date)
I - -
I
I
(Name 01Conrraa67) Qasu-dncc Compan}-/Pobq- Number) (Expiraoa Datc)
a ,
i
(Name of Coatmcior) (LQSuraac-- Compan-y/Policy Number) (Expiratioo Date).
(nQa,'r�l•+'t:�oca!tScC.if air---••ti.w incud:iafortna�oc pctniain�to.il oo�r-_c.o:�) -
O I am a. sole proprietor and have no one working for me-
( ) I am.,a home ovvoer performing all the work myself:
i
NOTE:pl—be nw-uc 0—wi le be xn'bo oXMploy pesana to LOO Cr rCP2�u•rork oa.d%%el-Z of
not @Oft tbcn Uh -l^ -La taiyc±�the bomoou-nr rceda rx oo the U-(Y s+ z,-,puRco,—Ihc-c'.o LT oo(c---rty—Z_-rtd to be
cmPloyes unl e the 1'0 k cr-.* --,'en A=(GLIt 52-=t(5)} Pptintion by a baa=o ae fcr c GaL_or permit ray nib—the
Ieg.7 ctzvc oC ea<tployx undo d.Wor4, 'coosp•omaLi A f- '
I
I undaztaad tba a oopy of thi. be fo�nvda.d b tbo Ocportm2a of Inc6it,icl/ucdc�a'OfGoe of 1,n�roc tha
eovQ-Ce vcrirc=tioo and Ihez L-il=c to seamt l-ovcry�a ta%dc suction 25A of MGL 152 c=lcxd to the=Posi6ca of aimiasl PCn Ili s
eomi iag oC■tint or up to S1}00.00:nNor�priy of up t.o oo yty end a vil pca ltia in 6,form of a Stop Work Ordc and n
run 0(:s 100.00.dry LPI=me
For d,,, t—ceVy
Pc7mlt NLmbcT
n
Ndap= LOt �.
s4LUrc oCLLctnscrlPcrnuttcc —Ulate -- )
SECTION 8-CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ���' 'l�C r�v� ALL (5 10 7
License Number
jAd4dr s Expir ation Date
Siure Telephone
4,Fte isle"rem i�o'me m�QVemerit ontracto "§ 1 �
„ _LOW' �� Not Applicable ❑
V-a .W , 4
Company Name Registration -um er - -- -
.�a-� ,'� �'r�5 ?r✓�.-� 'St Q�cuh�i c� �'� c� t o �c� j j - �.�.. - oS
Address Expiration Date
Telephone `!13 63`? 5-7_?9
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT`(M.G.L,c.1152,.§-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....".. M' No...... ❑
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
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check-all applicabie?
New House ❑ Addition ❑; Replacement Windows Alteration(s) Roofing ❑
Or Doors 0
Accessory Bldg. Demolition ❑ New Signs [oj Decks [M Siding[01 Other(C7j
Brief Description Proposed ,fir/ n
Wok ck-e I'm re r i t-h,
Alteration of existing bedroom Yes x No Adding new bedroom Yes X 'No'.
Attached Narrative x Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa:=1€ 1ev hoUSe�rid or ctd3toa a xist�ng:tior�s n(grc+oiirptete th,614 owtd4:
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:-OWNERAUTHORIZATION-70-BE-COMPLETED,.WHEN
.OWNERS AGENT'OR"CON7RACTOR`APPLIES.FOR BUIGDIFIG PERMIT
C A-,,,t----> as Owner of the subject
property //'� )
hereby authorize U`E'Y-CL If :y it'
to act on my bfehallf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date!
as OwnedAuthorized
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 tl�e pains and penalties of perjury.
Print a
Signature of Owner/Agent Date
Section 4. ZONING All Informatibit 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 d R
Side L: R:LL1' L:j=k�R=
mod: --`
Rear °
2�
Building Height
Bldg.Square Footage i %
Open Space Footage %
(Lot area minus bldg&paved r ' I ! i d
parking)
#of Parking Spaces
Fill:
a
volume,&Location '
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:, + 7
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO IX) 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 PON
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property? YES 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 , NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton IN
Building Department b
IP2 f'v
212 Main Street
Room 100 rtlUel iia rlt
x
Northampton; MA 01060
phone 413-587-1240 Fax 413-587-1272 0,10 any
APPLICATION TO CONSTRUCT,•ALT-E -ItEPAI�, EN�BHA R DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
} I This section to be completed by office
1.1 Property Address: FU LOS `ry"
S Q 0 Y_ P1,
Lot Unit:
OYerlay District
_ e
�� �� ;Elm St.Distnct � CB.District ? -
SECTION 2-'PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: \ 1
Na (Print) / Current Mailing Address:
Ll 6 '3v - s73v
Signature Telephone
SECTION 3-:ESTIMATED-CONSTRUCTION'`COSTS
Item - - Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 0oo O O (a)Building Permit Fee
2. Electrical o p (b)Estimated Total Cost of
0 Construction from 6
3. Plumbing ��O �, .� 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:
Building.Commissioner/Inspector of Buildings Date
File#BP-2005-0777
APPLICANT/CONTACT PERSON GERALD ARCHAMBAULT
ADDRESS/PHONE 263 PROSPECT ST PLAINFIELD (413)634-5739 Q
PROPERTY LOCATION 150 NORTH ST
MAP 25C PARCEL 008 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERM_ IT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction: RENOVATE ATT GARAGE INTO ACCESSORY APARTMENT
New Construction
Non Structural interior renovations
Addition to Existing
AccessoTy Structure
Building Plans Included•
Owner/Statement or License 010788
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9KMATION 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 S et Commission
12- o
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.
150 NORTH ST BP-2005-0777
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mau:Block:25C-'008 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-0777
Project# JS-2005-1085
Est. Cost: $11000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GERALD ARCHAMBAULT 010788
Lot Size(sq. ft.): 16683.48 Owner: ARCHAMBAULT GERALD R&MARY E
Zoning: URB Applicant: GERALD ARCHAMBAULT
AT. 150 NORTH ST
Applicant Address: Phone: Insurance:
263 PROSPECT ST (413) 634-5739 0 Workers
Compensation
PLAIN FIELDMA01070 ISSUED ON:314105 0:00:00
TO PERFORM THE FOLLOWING WORK.-RENOVATE ATT GARAGE INTO ACCESSORY
APARTMENT
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 3/4/05 0:00:00 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo