25C-225 E0AIIE O-WINER EXIEN-11-PTIO11-17 TVTEDGEA�NTT
The Sta:�o F�vffassaclius,-Vs c-lows tll,- tie lrighzr under 7SOC-ka 108.3.4 to
W owl-_S a ;Darc-- 012 w1hich he!slaeres;des orL,-,--.nds to be, a one ortwa fay zi�7
cached ordttached struc-.:L-.=S acceasory to such use and./or fa=structures.
person-W�lo Co'-I'!5-'rLjCtS=ore than one home in a v;vc-yewr penod sLaJT not be cor-isidere.d. a
Lome-Owner."
for t1l:e CI-4j o-c Norte,=-son wants persoz(s)who see-Ic to
use Lne L6ri-e'&wmer extmptioz, to a= as their ow-., a-w
tLzt L"-,r so vou- become r--Dorsible for Compli an C e wizza, Stm f C b UE d,in z codes
and ragul-fo as. �er m- sp e Lion p ro c ass-r eq L—e s that the e b uill di n g de;went be r--77 e d,
to i=—Oe--'work z Stllzes, which-include rbund2tionffootinzs Cbefore b2cldBA
50-Motube holes (before Dour). a rousli buildLz'ffisvectloir(before work is
can-ce �-hlzzu?-ti4a fnzz3ecti-0ag (ff reguL-ed) The
building de p,-,:-=enz r.-q=es
these ins-pe-c-tons,before,the woex is conceale,,l failure to
secure these ins-wec:uons can result in failure to obtain-a ce- eate of occur)ancv
Z Le h=--,e--waer Eire Other trades to pezfOrM woric Ph--mbing&Has) the
hc=to-wner-Wul be r--'Gnmble to zaak'el -Z -t that the tr es their proper
Lai cor-ji=cEon to bulldLing pe:'='t Issued, and that they get their required
L=Pectioas.Failure olc:He L--idii-vidu-al tra-Zes to se=- -e±e pf-,=ZS and ms:pectioras as
requ---� cz--.D.-FETAY tLe prqj--- i,-:::l such fd=e as the proper Perimn aad =b Per Ions are
made
uders —d the e above-
n
M.0-o — lresidtnes s1-=ature reques-dn-Y exemption)
W=H Call to seLed'u'll-a-IT required builduzg inspections necessary for the buildizz pe=ft
Issue."to me-
Dale
Ades&
locz�io
DffiFee of In vesti ations
i
600 Teas Langton St;-eet
Bosion 21
14 02M
w vw-mass.;owdia
'Workers' Compensation Insurance Affid wit: builders/Contractors/Tlectricians/Plumbers
Information Please Print Leglb'v
Name (Business/Organization/Individual): �JIt' e
-illtalfSJ-
City/State/Zip: 1��, c��. /�-e M// 616 3 Phone #: 6 3
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with *. ❑ I am a general contractor and I
employees (fiall and/or part-time).
have hired the sub-contractors 6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ R--nodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for mein any capacity. employees and have workers' 9. ❑ BuiIding addition
[No workers' comp. insurance comp. insurance.
'0.
required.] Electrical repairs or additions
�
". ❑ We are a cons oration and i s l ❑
3 I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No woi-lcers' comp. right of exemption perNlGL 1"'.❑ Roof repairs
insurance required.] _ c. 152, ysl(4), and w-e have no
employees. [ o workers' 13.❑ Other
comp. insurance required.]
`Any applicant that checks bex=1 must also fill out the section below showing their workers'compensation policy information.
Ho meowners who submit this affidavit indicating they are doing aIi work and then hire outside contractors must submit a new affidavit indicating such.
_Cone nciors that check 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 worriers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/StateiZip:
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 ofMGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP W ORK ORDER and a fine
of up to S250.00 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-cerzi unde-tlzeprdixs arts pe}ra?ties sf erja Flea the information provided above is true and correct
Simature:
Date:
6 s - 3 3 3 S
-=. f zcuaL.'tie-ar�l �ttlzrzt� tzlhis area to be completed bv�cily or town of ciaL
City or To`rYn: Permit/License it
i Issainff _authority (circle one):
I
! i. BO1rd rj?I-__+e�lth _. BZ1i Jiii_Departmen% _. l 'r„ i _� 1 � y r�i m Sra jn�
` l,-lt Yr 1 Vin Cle:1 lec_rical Inspector i L__ bi � L..Uector
I 6. Other �
C' :talc! D rStJ^ Drone ' '
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9 Registered Home Improvement Contractor:": Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M:G.L.c.152,§25C(6)j
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...... ❑
FIome Tuner gemptiin
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 1083.5.1.
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 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
N rthampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
omeowner Signature
L ' <
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[p]
Brief Description of Proposed ,,cr
Work: , iri',�Jv V5 t;�! yr:k- ✓�uL'iLoS�t door-' Oh � vZ"40Vv 'l SH5
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa._If New house and or addition to existing housingcomp ete fihefolEowing:
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, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature 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 .
Sign of Owner/Agent Xate
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 _ „ __ m •- -
oarkinO
#of Parking Spaces
Fill:
(volume&Location) -
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 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 C) YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location: i
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 0 NO 0
IF YES,then a Northampton Storm Water Management'Permit from the DPW is required.
' R
Department use only
City of Northampton Status of Permit_
building Department Curb Cut/Driveway Permit.
212 Main Street SewerlSeptic Availability
�vU Room 100 Water]W611 Availability
Northampton, MA 01060 Two Sets of Structural Plans.
phone 413-587-12 0 Fax 413-587-1272 Plot/Stte Plans
r '
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
ECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
<.-j.. Map Lot Unit
a� , . Zone District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT —J
2.1 Owner of Record:
.J W tr /l a [ 1�� -c::� I /1 /l �. JI /�•'-,. C,.�:�.V1 Ile
Name(Print) Current Mailing Add s:
�.(4 —S
Telephone
ature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ]?r g (a)Building Permit Fee
2. Electrical J (b)Estimated Total Cost of
Construction from 6
3. Plumbing 1 Building Permit Fee
4. Mechanical(HVAC) -'
5. Fire Protection
6. Total=(1 +2+3+4+5)
(7— DD Check Number ( `�
This Section For Official Use.Onl
Date
Building Permit Number. Issued:
Signature:
Building,Commissioner/Inspectoro- ui ings Date
' BP-2008-0811
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)
Cateuory: windows replaced BUILDING PERMIT
Permit BP-2008-0811
Project# JS-2008-001007
Est. Cost: $3500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 3484.80 Owner: ELIAS JULIE A
Zoning URC Applicant: ELIAS JULIE A
AT: 24 PARSONS ST
Applicant Address: Phone: Insurance:
13 HIGH ST
HAYDENVILLEMA01039 ISSUED ON:312512008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 2ND FLR REPLACEMENT WINDOWS
& DOORS
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:
"PHIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy SifInature:
FeeType: Date Paid: Amount:
Ciuilding 3/25/2008 0:00:00 $25.00121
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo