17C-017 (2) D escrlptor/Area
,: 2Fr/B
mood Deck 1152 sgfk
1 B:CFP
X56 132 sgfk
C: C FP
0 sgfk
DA Fr
60 sgfk
18 2Fr/B 18 E:FBAY
2 21 sgfk
F:Wood Deck
24 256 sgfk
5 -D 55 _�C 5
i� i 28
3 18
V
3
24
2.?
B
2
280.5
i
74.25 t C 016
74.25
1
f
116
292.12
1 2
74.25 17C-Oi7 74.2
305.11
4
i
82.5 17 C-O 18
82.E
i
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 7800,m 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 occupancv
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 own r/resid is signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date 41/ZJ 0
Address of work
location
Atmy— �
The Cotnmoi�weaith oflLlassachusetts
Detnarnment of IndfustriaJ_lccidenLs
n`^ o;lnves�ir~<cns
_ 000 Ffwshzngton Street
Boston, 31=I 02111
www'.mass.-o;ldia
tivorkers' Compensation Insurance Affidavit: Builders/'Contract ors,/Electricians,`P1r.Ilrbers
Applicant Information Please Print Lesibly
N=?— (Business'Organi:ariorv'Individual): _
Address:
City;%State,'Zip: Phone
Are you an employer? Check the appropriate boo: Type of project(required): I
1.❑ I am a emplo •e. with 4. ❑ I am a general contractor and I
y '� 6. ❑New construct-ion
emplovees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodelim
ship and have no employees These sub-contractors have S. Demolition
emplovees and have workers'
working for me in any capacity. 9. ❑Building addition
[-To workers' comp. insurance comp. insurance.:
required.]
5. ❑ W e are a corporation and its 10.❑Electrical repairs or additions
I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. o workers' comp. right of exemption per vIGL .,
fff y L ❑Roof repairs
insurance required.] ' c. 152, §1(=1), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that check;box#1 must also ill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new amdavit indicating such.
,Contractors that check this box must attached an additional sheet showing the panic of the sub-contactors 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 the policy and job site
information.
insurance Comr---,nanv Name —
Policy-` or Seif--ins. Lic. Expiration Date:
Job Size Address: City/State/Zip:
Attach a copy of the workers' compensation polio declaration pale(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of vIGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investizariors of the DLL:for insurance coverage verification.
I do hereby certify tinder the pain and pe aof perjury that the information provided above is trace and correct.
�a Date:
Phone
0,Jicial use only Do not write in this area, to be completed by city or town of ciaL
Citv or Town: Permit/License f
i
Issuing Authority (circle one):
1.Beard of Health 2.Building Department 3. City/Town Cie:k 41.Electrical Inspector 5. Plu_. bin.-Inspector
6. Other
Confiner Person: P.one
SECTION 3 -CONSTRUCTION SERVICES
,-I Licensed Construction. SuoerAsor: Not Applicable ❑
Name of License Hclder
License Number
"dcress Expiration Date
Signature Telephone
r.Reezistered Home,tmaroverite6tt OoafractQrw± w y Not Applicable ❑
.omoany Name Registration Number
.ddress Expiration Date
Telephone
ECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.452,§25C(6.))
'orkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit.
gned Affidavit Attached Yes....... ❑ 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. SLYth 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 buildinZ 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 15' (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be Iiable 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
/ortnampton Ordinances, State and Local Zoning Laws and Statte�of Massachusetts General Laws Annotated.
Homeowner Signature /
I -
SECTION 5-DESCRIP70N OF PROPOSED WORK(check all ar)oiicabie)
t
INew House Cj Addition Replacement Windows I Alteration(s) CC I Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition u New Signs n] Decks [LJ Siding[=,i Other=1
Brief Desorption of Froposed C
Work: �.J
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans At ached Roll -Sheet
6a. if New h6u- 2R( a�iaadniOnl fQ exiSiFTIQ h66sfha.comd4te the=fo[ av+rina.:
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 stores?
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. floodpiain 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 €0 SE COMPLETED_WHEN T.
OWNERS AGE T OR GONTRAC€OR APP L1E5 FOR BCfILDtNC PER N11T
as Owner of the subject
property
hereby authorize
to act on my behalf, in ail matters relative to work authorized by this building permit application.
Signature of Owner Date
1 as Owner/Authcrzed
Agent hereby declare that the statements and informat:on on the forgoing application are true and accurate, to the best cf my kncwiedgE
and belief.
Signed under the pairs and penalties of perjury.
f
Fnnt i j
i
^ ~
Section 4. ZONING ALL Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
This coittttin to be flill,�in by
Building Department
Lot Size
Fro�ntaze
Setbacks Front
Re
Building Height
Bidg, Square Footage %
Open Space Footage
(Lot area minu5 bldg&paved
#of Parkina Spaces
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
-\
/~� � u��
NO \~� DONTKNO�' \_� YES N��
`
IF YES, date issued:'Do
IF YES: Was the permit recorded at the Registry ufDeeds?
��
NO �� DONTKNOYY YES
�
IF YES: enter Book / ( Page and/or Document#| �
B. Does the site contain a brook, body of water orwetlands? NO DONTKNOYY 0 YES y=\
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobeobtaned y—\ Obtained �-� Date' v_� ' \_/ '
C. Do any signsexistontheproperty7 YES 0 NO
IF YES, describe size' type and location: ^ '
D. Are there any proposed changes toor additions cf signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E Will the construction activity disturb(clearing,grading, excavation, or filling)over acre oris it part ofaconmon plan
that will disturb ever I acre? YES � ] NO K�Y
~� ~u
IF YES, then a NortFamptohS5do�Wffe_r Min����ft-Pennit from the DPW isrequired.
Department use only
City or NOrt,2mpton status of Permit.-
_-- "_�L1r Department Curls Gut/Driveway Permit
r— �(�
_. 42 Main Street SewerlSepticavaiTabiIity
r 40M 100 WateiJWell Availability
�..
rtha ,'on, MA 01060 Two Sets of Structural'Plans
JUN pt�o�e 581-124.0 Fax 413-587-1272 PlotfSitePlans .
_ Other Specify
OjAa
APPLJ�i"d"+O�VjN� UCT R,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -S1TE_INrORNIATION
This section to be completed by office
1.1 ProDerty Address, //e ("✓�J j,
/0 /�'lapl Map Lot Unit
00 dd Zone Overlay District
Elm St District CS District
SECTION 2-PROPERTY OWNERS HIPIAUTHORIZED AGENT
2.1 Owner of Record:
MA9V
Name(Print,,,)///►►►!!! _ Current Mailing Addre WWITelephone (J 7
Signature
2.2 Authorized Agent:
Name Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item I Estimated Cost(Dollars)to be Official..Use Only
completed by vemit wolicant
1. Building �!,`�• �` (a}But7ding Permit Fee
Vo
2. Electrical VV j_(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) Check'Number-
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
-- -- --- ------
Building,CommissianeT/lnspecto�of Ewidings "' " Gate
File#BP-2008-1126
APPLICANT/CONTACT PERSON JENKINS MARY ANN
ADDRESS/PHONE FLORENCE
PROPERTY LOCATION 106 NORTH MAPLE ST
MAP 17C PARCEL 017 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
T_ypeof Construction:_ERECT 8 X 8 SHED
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 FQrLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
0//1724:�1043?
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.
e +
:; BP-2008-1126 no
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)
Category_ BUILDING PERMIT
Permit# BP-2008-1126
Project# JS-2008-001656
Est. Cost: $25.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 22302.72 Owner: JENKINS MARY ANN
Zoning:URB Applicant: JENKINS MARY ANN
AT. 106 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
FLORENCEMA01062 ISSUED ON.612012008 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 8 X 8 SHED
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 6/20/2008 0:00:00 $25.003957
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo