41-008 (3) C 0 INIA G.,CeO
iii -VT DGEINIETINT
k."I JER LE
I 7"r.P righ- under 78GC__`,fR IOS-3.4 to
s allows tae hom eowner the ELL
L. cons, c 'on E, sza-t- P r TIN
i zq_(�t a�-: uTL LI T�:
nes omec; e
wR r" a d so-
who ovms a parcel on which he!shl e resides or intends to be, a one or twofayn4y
Ywef.,.-.g, az:aached orderached Strucz:-es acc4ts-ory to Such use and/or famm 5=C,=-I'S.
pC,-:;,on-Vyho ConStrLICt✓ more tar period shall not be considered a
One hOMt-in, a t7NC-,' s
home o-vner."
The b depai for isle CiV GIE Nor-LIIELMOton Zn- Y p ) who Seek to
Use the hom--- C-Winer exemption, to ac" as their C)-V;ir CCnstr==
that by doing so you become responsible for compEance with state building codes
and reg-allations. The process requires that the building deparuent be called
to inspect wori at various Stages, which include foundation/footings rbefore backTIIA
SO-notube holes (before Dour). a rough building insvection.(before work is
caammled), i�sulation in_S_�ectian (if reguired) The
bu_Eding department requires these inspections before the moors is concealed, failure to
secure these. inspections can result in failure to obtain a certificate of o.ccupancv
umtilthe-w-oa k
UF the hires other trades to per form work(electrical, plumbing&-gas) the
ho=-_OvvmeI--Vvul be fesuoasi,r
,le to r4--l-e Sure *'gat tI:e trade, hired
secure the ir
proper
cnnuJimctIon to Lae building pef1111t issued, and that they get their required-
inspections-Failure of the ladi-,,Idual trades to s&-m-.re the pe,• '7-s and inspections as
requLred. can DEIAY the project, umIL Such time as the proper pem-ts an inspections
ar
Marie
un.der:7,an. d the above_
(Homy_owner/resident's si!znature requesting ememption)
I`i-T1 Call to SCiledLTe a required build- inspections z necessary for the b ull dlni g ermit
-111 re i building in- :ons
Issued to me.
Date
' Department of Industrial Aecidents
Office of Investigations
600 Washington Street
Boston, i I-A 02111
WWW.mass.1 ov/clia
Worl,,ers' Compensation Insurance :affidavit: Builders/Contractors/Electricians/Plumbers
Aunilicant Information Please Print Legibly
Name (BusinessiOr anization/bidividual): 41e'L,- rAlla0ei IV�i�4�8�'`�
City/State/Zip: 7 Phone 'S�
Are you an employer? Check the appropriate box: Type of'project(required):
. I am a employer'with 4. ❑ I am a general contractor and I ❑
employees (full and/or pant-time).* have hired the sub-contractors
6. New constntction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. [7 Dernolition
wonking 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.[] Electrical repairs or additions
❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per INIGL 12.❑ Roof repairs
insurance required.] - c. 152, ;1(4), and we have no
employees. Ni o workers' 13.7 Other
comp. insurance required.]
*Any applicant that checks box=1 must also fill out the section below showing their workers'compensation policy information.
Ho-neowners who submit this affidavit indicatins they are doing all work and then hire outsidecontractors must submit a new affidavit indicating such.
Contr actors drat 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 empioyees,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 Company Name: &6e,)dle-d Cif p(lyv,S Y1,1S,
Pohcv�=or Self-ins. Lie. 5'0 d O 6 Expiration Date:
Job Site Address.- L, �_ C-0 ,d V e- City State/Zip: /fd11'1J1AyNp 7d r
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 c. 152 can lead to the imposition of criminal penalties of a
tine up to S 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
investigations of the DIA for insurance coverage verification.
I do hereby cerfrarndc�r tiropains rrne�penakies-ofperjarry that-the information provided above is true and correct.
S ianature� Date
7
Phone = 4t'7
FrriciaL .. _ _ city or town offichd-- -_
City or Town: Permit/License m
Issuin,Authority (circle one):
1. Beard o1.ueaith 2. Building, Depart nent 3. CitviTo,vn C1eri�- -'.. Electrical Inspector 5. Plumbin, Inspector
fi. Oti ti r I�
t_ :ctact Person: Phone ,.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder ® ? !:�a 6
License Number
'�) vi S ,�(Jn S l� £�S l�ral�p fir, -� U 9
Address y� Q��� Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Nut Applicable ❑
Company Name Registration Number
a 3 -
Address [� Expiration Date
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 building permit.
Signed Affidavit Attached Yes....... V 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 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[o] Other
Brief Description of Proposed ]1
Work: av'� fhTfri ?/, d lq,-,vse /t �Pec7 ST►/fit'Ici'� gtr j c.�(/✓c'
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. flcodplain 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
Own /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to th s of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner(Agent Date
Section 4. ZONING I Alt 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
oarkintz)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW C) YES 0
IF YES: enter Book Page and/or Document#,
B. Does the site contain a brook, body of water or wetlands? NO 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 e
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
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb CuttDriveway Permit
r^ � 212 Main Street Sewer/Septic Availability`
Room 100 Water/Well Availability
North mpt0h, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot(Site'Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1lP�ryoperty Address:
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signa re
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
com leted by ermit applicant
1. Building (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) DO U• oe Check Number
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
- _ 9 . -- io- _P -• g
Buildin Commissioner/Ins ector dfBuiidms Date
File#BP-2009-0434
APPLICANT/CONTACT PERSON THOMAS BACIS
ADDRESS/PHONE 67 DIVISION ST EASTHAMPTON (413)529-0801
PROPERTY LOCATION 45 LOUDVILLE RD
MAP 41 PARCEL 008 001 ZONE RR(100,//WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: INTERIOR DEMOLITION TO INSPECT STRUCTURE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 070061
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFF�MATION PRESENTED:
10 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
o U 0ty
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.
BP-2009-0434
GIS#: COMMONWEALTH OF MASSACHUSETTS
x 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-2009-0434
Project# JS-2009-000587
Est.Cost: $5000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THOMAS BACIS 070061
Lot Size(sq. ft.): 123231.24 Owner: BACIS PROPERTIES INC
Zoning: RR(100)//WP Applicant: THOMAS BACIS
AT. 45 LOUDVILLE RD
Applicant Address: Phone: Insurance:
67 DIVISION ST (413) 529-0801 WC
EASTHAMPTONMA01027 ISSUED ON.1012012008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INTERIOR DEMOLITION TO INSPECT
STRUCTURE
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 10/20/2008 0:00:00 $55.004298
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo