46-050 (2) City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a'properly
I" erased solid waste disposal facility, as defined by MGL c 111, S'4,,50A.
Address of the work:
r
The debris will be transported by: / ,
The debris will be received b
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Building permit number:
Name of Permit Applicant K /
Date Sign-ature of Permit Applicant
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Fes', ter. Northampton, MA 01060 �sWip 7i�j���
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION�4CKNOWLEDGEMENT
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 any 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 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 inspectioi giade
I,
understand the above.
V (Home owner Tres ent's signature requesting exemption)
will call to schedule all required build' fispections necessary for the building permit issued to me.
Date ! I
Address of work location
I
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
f Boston, M 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Bunters/Contractors/Electricians/Plumbers
licant Information �" f Please Print Le ibl
aisle (Business/Organization/Individual): {/`
Address: I ` l
City/State/Zip: Phone#:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. E] I am a general contractor and I
employees (full 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. ❑Remodeling
ship and have no employees These sub-contractors have 8. []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 10.0 Electrical repairs or additions
3.`E�I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
(l `myself. [No workers' comp. right of exemption per MGL 12.F�Roof repairs
insurance required.] t C. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners 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 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 the policy 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 c. 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 un he pains an ena es of rjury that the information provided above is true and correct.
ature: ,° Date: Z -
Phone#:
Of 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
Not Applicable £
9 Reaisfered_Home.Improvement.Coriti•actor_�__�:,�__.,.__.�___,_�.,� �_._._::__ __.._�._:=
Company Name Registration Number
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....... £ No...... £
11 Home Owner<:Ege npt><on
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-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,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"terrifies and assumes responsibility for compliance with the State Building Code,City of
; orthampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature, ��
l
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors F
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [Q Siding [❑] Other[❑]
rDescription of Proposed
'fled , ZI t tion of existing bedroom Yes \/ No Adding new bedroom Yes . Noed Narrative Renovating unfinished basement Yes No ans Attached Roll -Sheet
Newhouse:and:of.addI,ion to`exlsfing.houslnQ;=complete the.followlnc:
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 Ta-OWNER AUTHORIZATION N-TO BE COMPLETED WHEN
. OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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
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
ignature of Ow r gent Date
r -
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
TIiis column to be filled in by
Building Departrnent
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has o Special Permit/Variance/Finding ever been issued for/on the site?
x�� x,� ��
NO ��' DON7KNDW v�� YES �~�
/F YES, date ioued:
IF YES: Was the permit recorded at the Registry ufDeeds? /
NO � uuM | xnuv 'c�
IF YES: enter Bonk Pagel and/or Ducument#
B. Does the dtecontain a brook, body of water orwetlands? NO DONTKHOY/ 0 YE�
IF YES, has permit been or need tn be obtained from the Conservation Commission7
Needs to be obtained ~��~\ ^_/Obtained �-� Date Issued:
� '
C. Do any signs exist on the pmperty �� ��� YES �.� 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, gradingexcavation,or filling)over 1 acre oriou part ofa common plan
' that will disturb over 1acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required. |
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jj Department'U52Only
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ort ampton, MA 01060 Twa Setsaf Strtrctbral Pias
---- t}arse 413- 7-1240 Fax 413-587-1272 :PIbf/Slte Pians l i y 4
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APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
f. SECTION 1 -SITE.INFORMATION
Property Address:
Map Lot Unit.
-
/� - -
r,��Y� Zone- � Overlay Disfrtct" r
EIm�St�Dstncf=� i 1`'GBeDtstttct-; '�
SECTION 2.7 PROPERTY OWNERSHIP/AUTHORIZED AGENT'
2.1 Owner of Record:
IW A-C
Name(Print) Current Mailing Address:
1 Telephone -�-
Signature
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. uilding (a) Building Permit Fee
Electrical (b)'Estimated Total f Cost of
Construction'from' 6
Plumbing Building Permit Fee
Mechanical(HVAC)
Protection
6. Total=(1 +2+3+4+5) See) Check Number
This Section For Official Use Onl
. -.
Building Permit Number: pate
Issued:
Signature:
Building Commissioner/IrlspectoCof Buildings; ,: Date
a -
File#BP-2016-0720
APPLICANT/CONTACT PERSON ZAJOWSKI KATHRYN
ADDRESS/PHONE 99 ISLAND RD NORTHAMPTON01060(413)586-1533 Q
PROPERTY LOCATION 99 ISLAND RD
MAP 46 PARCEL 050 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid r
Building Permit Filled out �.
Fee Paid
Typeof Construction: REMOVE PLASTER&SHEETROCK&INSULATE WALLS
New Construction
Non Structural interior renovations Iga 2
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
col' ' 10a
Si eof uil mg icial 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.
99 ISLAND RD BP-2016-0720
GIs#: COMMONWEALTH OF MASSACHUSETTS
MapBlock: 46-050 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2016-0720
Project# JS-2016-001204
Est. Cost: $500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. 1): 3484.80 Owner: ZAJOWSKI KATHRYN
Zoning: Applicant: ZAJOWSKI KATHRYN
AT. 99 ISLAND RD
Applicant Address: Phone: Insurance:
99 ISLAND RD (413) 586-1533 0
NORTHAMPTONMA01060 ISSUED ON:1112412015 0:00:00
TO PERFORM THE FOLLOWING WORK.REMOVE PLASTER & SHEETROCK& INSULATE
WALLS, ENLAFNTERIOR DOOR OPENING
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 11/24/2015 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner