25C-151 (2) Lt=npcor, MA 01060
I- A A EW01V EDGE, IENT
-L- C. L
k-,' ER EX
I 7-1-he Stan o--,c'M-assachT:se-r,-s allows 'U-I-- horn--owner the ri-crliL under 780CMR 108.3-4 to
"
act aE Construcrior r, Sur,� 'he -IeEzes "Homeo wner a -Son(s)
who owns a parcel on which he/she resides or intends to be, a one or twofandly
attached or detached structures accesS iy to s, ccures.
uch, us.e and/or fa---,,2 S--L
person who con.-,tracts more than one home in a n-vo-ve-ar period shall not be considered a
home o7,mer--
T-he bur ding--departm ent., for t-lae City offNor-,h,-=pton want's any person(s) who seek to
constr to n7=7-i-
U S-1 the home OV-,Me,-exemption, to act as their Own
that by doing so vou become responsible for compliance with state building codes
and regulations- The inspec-Lion process reeqluires that the building departm, ent be called
to i=. per work at various stagges, which include foundation/footings Cbefore backFIAM.
sonotube holes (before oour). a rough building inspection:(before work is
car.ceidedI i-Rsulati" insuectian (if reguhred) The
building depar=ent re—quires these inspections before the work is concealed, failure to
secure these. inspections can result in failure to obtain-a certiBcate of occuo:ancv
umtil the-w-ar-k-can-be insuected-
L-7the homeowner hires other trades to per dorm-work(I.ectrical, plumbing&gas) the
homeowner will be responsible to mare sure thaft the tracfes hired secure their proper-
per its in conj,--ction to the building pe=t issued, and that they get their required
inspections.Failure o.-Fthe individual trades to secure the pe.-Mits; and inspections as
requ.;redf can DELAY tie prc)j----, until such time as the proper permits and inspections are
made
=,derstand the above_
(Home_owner/resident's signature requesting exemption)
I will call to schedule all required building inspect ions necessary for the building pe.-rrut
Issued to me.
Date
Address_
locanor.
Le ct,tP�tettl of d, �tts�,-1 �ccat 1-1
Office of In��estigations
600 tlashiniton Street
Bostfln, 31A 02111
n w.naass.,1%
w dia
Workers' Compensation Insurance Affidavit: Builders/Con tractors/Electricians/Plumbers
A nplicant Information Please Pririt Leaiulr
Name (Business:OrLanization,-Individual):
City/State/Zip: I'tai 4W 70 iJ �ul,� 01�U Phone #:
Are you an employer? Check the appropriate box: Type of project(required).-
1. �I any a em foyer-with ❑ I am a general contractor and I
p 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
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.,
required.]
5. ❑ We are a corporation and its 10.F71 Electrical repairs or additions
❑ I am a homeowner doing all work officers have exercised their 1 I.E] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.7 Roof repairs
insurance re uired. c. 152. §1(4),, and we have no
q ] employees. [TNo workers' 1 ❑ Other
comp. insurance required.]
'Any applicant that checks box 7,1 must also fill out the section below showing their workers'compensation policy iliformation.
Ho meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
-CUnllaCLors that checi<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 thepolicy and job site
information.
Insurance Company Name: -
Policv t#or Seif--ins. Lie. n: WC�
�� �/5 — �� J`721 7 Expiration Date: 0,�; /57- -
` t�Fc..6p,�10 .�" Ci /State/Zi 'I. o �`l�9w,,1TEJ lG1.,
Job Site Address: /?-'//, n' p' � ��
Attach a copy of the workers' compensation policy declaration page (showing the policv 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 S 1, 00.00 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 for-arded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerrifi-under the patrrs rrntl pens ties-o pe>Juin�that-the information provided above is tare and correct
Signature:
Phone T 7
__ l_OficiaLuse..orall �u uut�vritenlhis_ate_a4 to be completed _city or town offcicrl
— ---
----- -City or Town: — -- -- Permit/License m
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Civ,/A own Clerk 4.Electrical Inspector Plumbing Inspector
I
o. Oilier �I
Contact Person: Phone
u
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction ySupervisor: Not Applicable ❑
Name of License Holder:
License Number
1 2 A5
Address Y Expiration Date
Signature Telephone �� (3/0
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
7 i f5�j 4, , w 7f i�0�l
Address Expiration Date
/,&c X7,4 f� 'er' 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 buildipg permit.-
Signed Affidavit Attached Yes....... IV 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-vear period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official, on a form acceptable to the Building Official.that be/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 W" dows Alteration(s) Roofing ED
Or Doors [ta
i
Accessory ld ❑ Demolition g [ ] [M Siding [2e/ Other[C]]
ry g. New Signs C7 Decks
Brief Description of imposed
Work: N i A l 1 t'i PJ, !(i?. �4/E N, t:Je<a -�'
/
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?
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
I. !/l�✓� �' �� as Owner of the subject
property
hereby authorize _ � � r'3 g,4 1
to act on my behalf, in akmatters relativ to work authori ed by this building permit application.
Signature of Owner Date 's—j o- olf
1,_ J�E7'0'' b() '0�, as QY"r/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 QWW/Agent Date 3 -75`7-0 '
I
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 Parkins;Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q 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 0 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
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 O NO Q
IF YES, then a Northampton Storm Wat&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
1 v Northampton, MA 01060 Two Sets of Structural Plans
v phone 41.'-587\'1240 Fax 413-587-1272 P16VSite Plans
Other Specify
APPLIGAt'6Ii'TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION,.---SITE INFORMATION
1.1 Property Address:
This section to be completed by office
)2 17 tJ Map Lot Unit
✓� ''0' � Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) 7 � r Current M4Wr)g Addre k XA Q>�
Telephone
Signature -5 S3001
2.2 Authorized Agent:
Name(Print) Current Mailing AddrE s: It
Siglinature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building G (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) v v Check Number
This Section For Official Use Only
Building ermit Number:
Date
Issued:
Signature:
Building Commissionei/Inspector ofBuil mgs Date
BP-2008-0766
GIs#: 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)
Cates,ory: BUILDING PERMIT
Permit# BP-2008-0766
Project# JS-2008-001184
Est. Cost: $24850.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
('oast. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq. ft.): 601128 Owner: BATTEY MARK A&JOY A
Zoning: URB Applicant: B & R Siding
AT. 17 ORCHARD ST
Applicant Address: Phone: Insurance:
781 Bridge Rd (41-1) 586-4167 Workers
Compellsgtloll
NORTHAMPTONMA01060 ISSUED ON:311112008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS & SIDING
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 Occuipancy Si nature:
FeeType: Date Paid: Amount:
Building 3/11/2008 0:00:00 $25.0021176
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo