36-075 (4) I
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City of Northampton 212 Main St eet, 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
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: VAS'O'L_ 6U4qk' W
The debris will be transported by: h
The debris will be received by:
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Building permit number-
Name of Permit Applicant J �'
Date Sign-ature of Permit Applica
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City of Northampton
Massachusetts
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{'">'r.-��• .=.�.' s:_'• DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Munici al Building
Northampton, MA 1060
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INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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HONE OWNER EXEMPTION ACKNOWLEDGEMENT
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The State of Massachusetts allows the homeowner the righ 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 dwells g, 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 ny person(s) who seek to use the home
owner exemption, to act as their own construction superviso1, to be aware that by doing so you
become responsible for compliance with state building odes and regulations. The inspection
process requires that the building department be called to in pect work at various stages, which include
foundation/footin s before backfill sonotube holes before pour), a rough buildinq inspection
before work is concealed insulation inspection if re !red and a final building inspection.
The building department requires these inspections before th work is concealed, failure to secure
these inspections can result in failure to obtain a certific to of occupancy until the work can be
inspected. t
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be i
responsible to make sure that the trades hired secure their pr per 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 insp ctions are made
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understand the above.
(Home ow er/resident's signature requesting exempti n)
I will call to schedule all required building inspections necessa for the building permit issued to me.
Date >t—L o
Address of work location
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The Commonwealth oflMlassachusetts
Department of Industrial Accidents
-.�---
Office of Investigations
600 Washington Street
r Boston,M4 02111
www.maSS.goV/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLyibly
Name (Business/Organization/Individual): I 00th
Address: o 1 /0 1-
�l b r) e
City/State/Zip: r^ L
0� Phone#: �S
Are you an employer?Check the appropriate box: Type of project(required):
4. 7 I am a general contractor and I
1.❑ I am a employer with 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet. 7. 'Remodeling
ship and have no employees These sub-contractors have g, �Demolition
working for me in any capacity. employees and have workers' 9 Building addition
[No workers' comp. insurance comp.insurance.$
quired.] 5. 7 We are:a corporation and its 10.0 Electrical repairs or additions
3.�am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 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 mustprovide 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 o the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure overage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 1,500. 0 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$21A0.00 a �'against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigatio of th IA for insurance coverage verification.
I do hereb ti u r he ins andpenalties ofperjury that the information provided above is true and correct.
Signature: Date:
Phone#• L L LIZ 14)
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#:
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Holder
License Number
a
Address Expiration Date
Signature Telephone
9.Regisfered_H'ome Improvement Contractor ♦? _ Not Applicable £
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M. .L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitte�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...... £
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11 .:`Home pwner�Egempt><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 o*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 d¢tached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a o- ear period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a fo acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building emit.
As acting Construction Supervisor your presence on the job site gill 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 Massachusetts General Laws Annotated.
Homeowner Signature,
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
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New House F7 Addition ❑ Replacement Windows Alteration(s) ❑ Roofing F7
or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [[ ] Decks [[] Siding [O] Other[p]
Brief Description of Proposed
Work: tZ GLIB v C V1 h P (!�, S kit
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Alteration of existing bedroom Yes_L," Adding new bedroom Yes _jZ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6'a. If New haa`se acrd or-addlt�on#o existlnq'fousin'g, complete the fo lowing:
a.' Use of building : One Family_�� Two Family Other
b. Number of rcoms 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? I vo
f. Method of.heating?_ 1\ 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 �o. Is construction within 100 yr. floodplain Yes CN0
j. Depth of basement or cellar floor below finished grade 4 ji'e-�
k. Will building conform to the Building and Zoning regulations? _ L/0' 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
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
4herdecf�are as Owner/Authorized
A hat the statements and information on the foregoing application are true and accurate,to the best of my knowledge
an Si d penalties of perjury.
Print a e,� 'N ) "'b '1'C' -Z' 1�
Signature of Owner/Agent Date i
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Section 4. ZONING AR Information Must Be Completed. PerrT 0t Can Be Denied Due To Incomplete Information
Existing P�oposed Required by Zoning
TIiis column to be filled in by
Building Departuie
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage
Open Space Foota
(Lot area minus bldg&pay
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Variance/FindinZ ever been '�sued forlon the site?
IF YES, date issued:]
'IF Y-_. Was -- permit_ recorded at the Registry of DOds? .
IF YES: enter ook Pag and/or Document#
B. the �teconta brook, body of �r wez� �
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
0 .
C. Do any signs exist on the r#? YES NO
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IF YES, describe size, type and location:
D. Are there any proposed changes- - or additions of signsl
IF YES, describe size, type and tocatiul-L.
E. Will the construction activity d/smno(clearing, grading r filling)over/ acre orisx part o,a common plan
' that will disturb over 1acre? YES NO
|F YES,then a Northampton Storm Water Management Penni from the DPW iorequired. �
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Departm rtl a �i
City of Northampton _Sfat`us ofP�rrrid -r� - � �- err T
Building Department Gorb CurEDriye�vay Permit
< y`r 212 Main Street SewerlSeetieavaiCa6illty
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Room 100 UUater/UeltAva�laliility
Northampton, MA 01060 lwa,SetsofS#rictural PIa[ts y
phone 413-587-1240 Fax 413-587-1272 PIoflSite PEans' "T _ r
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APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION.
1.1 Property Address: _ This sectiorrfo be completed by office
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� Map Lot Unit
Fes-... .... .r '
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�-'/a`✓-� � �`� r���G Zone � Overlay Disfrtct -
-: —
EIm St:District 1
- CB District
SECTION .=PR PERTY OWNERSHIP/AUTHORIZEDAGENT'
2.1 Own of Rei ord:
Name(P nt) Current M ing ddress-
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. Building �l/ ry (a) Building Permit Fee
2. Electrical / (b) Estimated Total Cost.c
o G Construction from (8):'
3. Plumbing J6 4l Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This.-Section For Official Use Onl G"
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector`of Buildings..':..'*: Date
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File#BP-2016-0779
APPLICANT/CONTACT PERSON HOENER VIRGINIA
ADDRESS/PHONE 289 Elm St NORTHAMPTON01060(413)584-6489 Q
PROPERTY LOCATION 363 WESTHAMPTON RD
MAP 36 PARCEL 075 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REPLACE CEILINGS&INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 setspf Plans/Plot Plan
THE OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I F RMATION 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
-Demolitiou Dela
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.
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363 WESTHAMPTON RD BP-2016-0779
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 -075 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-0779
Project# JS-2016-001321
Est. Cost: $12000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 93697.56 Owner: HOENER VIRGINIA
zoning: Applicant: HOENER VIRGINIA
AT. 363 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
45 PINE ST (413) 584-6489 0
FLORENCEMA01062 ISSUED ON.1211412015 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE CEILINGS & INSULATION
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 12/14/2015 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner