12C-084 (2) ,a
�yY
Quick Open Space Calculations Coverages.
existing 72
Lot area existing proposed existing 960
10579 1132 1692 existing 100
existing
Open Space 9447 8887 existing
total 1132
Open % 89.3% 84.0%
new 560
new
new
total 1692
Ct 2-CA K�-
„ i_
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines"Homeowner"as, "Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants 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 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 m 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
ze).2 understand the above.
J (Home ovvidr/resident's signs requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location 0:I r .Tr-•lcy k,P0-'5
The Commonwealth of Massachusetts
.— Department of Industrial Accidents
Office bf Investigations
600 Washington Street
Boston MA 02111
`-` www.massgovtdia
Workers' Compensation Insurance Affidavit:Builders/Contractors/E.lectrieians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/lndMdual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box. Type of project(required):
1.Q I am a employer with 4. ❑_I am a general contractor and I
employees(full and/or part-time)-
s have hired the sub-contractors 6_ Q New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Q Remodeling
ship and have no employees These sub-contractors have 8. Q Demolition
working for me in any capacity. employees and have workers' 9. Q Building addition
[No workers'comp.insurance comp.insurance. 10. Electrical repairs required.] 5. Q We are a corporation and its ❑ ep s or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.Q Plumbing repairs or additions
myself. (No workers'comp. right of exemption per MGL
12.Q Roof repairs .
insurance required]t c. 152,§1(4),and we have no l3 Q Other
employees. [No workers'
comp.insurance required
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
;Contractors that check this box=tW 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 awn provide their workers'comp.policy number.
lam an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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 e. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/ I do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct
l/ Signature:
Phone#: 3 - ;5 S"71 "77
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
C
9.Registered Home Improvemnt eontractor`. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAYIT'(NI G:L:
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...... ❑
11.. r: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 10835.1.
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,von 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 c� '"i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[CI]
rief Description of Proposed Po rrr�v- ru F',,V ��'2 �Q'X a S C A is to N re H 40 2 m
/Work: �ucL`„i� �P �G,, -!/�3)4JVV /1L S.:, /1cCcCr>✓� Ari 1� iiw�R "r"?, j'f.7'Airur�lc;.cfk'ZC`�i.irp,pmw I'1r 9.ateir
a� 7'-Nd► 1J.4rr.'�W1�1y'.
Alteration of e)dsting 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 addidbft td_e6 fil U 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. Masschecic 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.
1. Septic Tank City Sewer Private well City water Supply
SECTION.7a-OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES'FOR BUILDIN G 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 NameIJJ,h-y/�J�yt ✓+C'r'`�'• {�
Signature of owner/Agent Date
Section 4_ ZONING AU Information Must Be Corpleted.Penntt Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be fined in by
Sw77 rwg DeImunew
Lot Size
Fronts e
Setbacks Front
---� - t 5- p
Side L::--.-3 RL=__ ' L:= Rj ' .
Rear F f
Building Height
Bldg.Square Footage L %
i 3
Open Spatz Footage % _ C7
{La uea muau Mg Rc paved
#of Parking Spaces
Fill:
volmne&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 rec rded 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 0 YES 0
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 0 NO 0
IF YES, describe size, type and location:
D. Are there arty proposed changes to or additions of signs intended for the property? YES 0 NO Q
IF YES, describe size,type and location:
E WHI the construction activity disturb(dearing,grading,excavatiar,or fiWwQ)over 1 acne or is it part of a common plan
that wiA disturb over 1 acre? YES 0 NO 0
IF YES,then a Northampton Storm Water.Managernent Permit from the DPW is required_
s
Depaxtment`Lise only
City,of Northampton status of Fecz►iit
Building Department Curb CutrDriewrray Peimit
1.212 Main Street SewedSepticAvaitabifityr
Room 100 WaterNtleq Availabrfity'_ ,
Nprtha#;npton, MA 01060 'Fv�o Sets of Structural flfanS
phone 4*0-587.41240 Fax 413-587-1272 PIotlSrt+e Plans
_..__-. Otherspecxffr
APPLICATION TO CONST,1fVL ALTER,REPAIR.RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
AW
SECTION 1-SITE 'TION
This section tote=completed by ot1'ice
1.1 Pro aerty Address:
.� Map.. `i.:ot Unit
f r
- Zone Overlay District
` ' t7irx St! Strict CB District
SECTION 2-PROPERTY Oillit+fERSHIP)AUT-HORfZ Q-AGEFI
21 owner of Record-
. _
Name(Print) Current'Ma :
— ' "' 2'77
-rte
Signature
22 Authorized Agent:
Name(Print) Current MaFM Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUgTJON GOSTS:
Item Estimated Cost(Dollars)to be Official Use Only
completed b
1. Building 6,QV,1L F. = a 4 } 9..�'et�nit•Fee
2. Etedrical ( ota€Oost of
rct�on=froei-6
3. Plumbing =Budding--
i ,EFee
4. Mechanical(HYAC)
5.Fire Protection
6. Total=(1+2+3+4+5) 3 0 Ctedc;Number
T[►fsSeclionForfat Use On
-Date
Building Permd Number. - tssued-
Signature:
Bu*wV Commissiorwfirispector of BuadRrgs. Date-
File#BP-2008-1183
APPLICANT/CONTACT PERSON BROWN WAYNE E&ELEANOR J
ADDRESS/PHONE 44 MARY JANE LANE FLORENCE (413)584-2779 Q
PROPERTY LOCATION 44 MARY JANE LANE
MAP 12C PARCEL 084 001 ZONE URA Wz;?
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 116V 0 0"1
T_ypeof Construction: CONSTRUCT 20 X 28 DET GARAGE FOUNDATION,8/22/08 AMEND TO ADD
RETAINING WALL/FOUNDATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 Commission Permit DPW Storm Water Management
Demolition Delay
Z
Signature of Buildi g Offi ial 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-2008-1183
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-1183
Project# JS-2008-001743
Est. Cost: $3000.00
Fee: $160.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq ft.): 10585.08 Owner: BROWN WAYNE E&ELEANOR J
Zoning. URA Applicant: BROWN WAYNE E & ELEANOR J
AT. 44 MARY JANE LANE
Applicant Address: Phone: Insurance:
44 MARY JANE LANE (413) 584-2779 ()
FLORENCEMA01062 ISSUED ON.613012008 0:00:00 Va--
TO PERFORM THE FOLLOWING WORK.-CONSTRUCnP 28 DET GARAGE
FOUNDATION,8/22/08 AMEND TO ADD RETAINING WAI I /FOUNDATION
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 6/30/2008 0:00:00 $160.001986
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
,r
PLAN OF LAND IN
�\ NORTHAMPTON MASSACHUSETTS
Prepared for&by
Eleanor J. and Wayne E. Brown
June 24th 2008
N - �
'OSED
c 28']
AGE
i
3 French
Drain
i
44 PROPOSED
[22'x 28']
GARAGE
Driveway j
- --- 1- ----- —-\ -- -— --J ------ --------
RICK DRIVE ---_____-_-__-SCAL -
5' 40'
�. 10'