24D-067 32 Perkins Ave Building Permit Application 5.16.17City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
Department use only
Status of Permit:
Curb Cut/Driveway Permit ____________________
Sewer/Septic Availability______________________
Water/Well Availability________________________
Two Sets of Structural Plans___________________
Plot/Site Plans_____________
Other Specify__________
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
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
2.2 Authorized Agent:
______________________________________________________
Name (Print)
______________________________________________________
Signature
______________________________________________________
Current Mailing Address:
___________________________________________________
Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be completed by permit applicant Official Use Only
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)Check Number
This Section For Official Use Only
Building Permit Number:_______________________________ Date Issued:______________________________________________
Signature: ______________________________________________
Building Commissioner/Inspector of Buildings
_______________________________
Date
32 Perkins Avenue
Northampton, MA
01060
Danielle J McKahn 32 Perkins Avenue, Northampton, MA 01060
413-320-7208
$25,000
$30,000
_____________________________________________________ Signature
$3,000
$2,000
Section 4. ZONING All 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
Rear
L:______ R:______
NA
L:______ R:
______
Building Height
Bldg. Square Footage %
Open Space Footage
(Lot area minus bldg & paved
parking)
%
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? 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 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 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
6,185 sq. ft.6,185 sq. ft.
NA NA
NA
11' 11'
(new deck stairs)
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House Addition Replacement Windows
0r Doors Alteration(s) Roofing
Decks [ ]Siding [ ] Other [ ] _________________________________________________________________ Work:________________________________________________________________________________________
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. 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 .
l. 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
I, Danielle McKahn _____________________________________________________________________________________, 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
__________________________________________________________________________________________________________
Signature of Owner/Agent Date
X X X
Accessory Bldg. Demolition New Signs
Brief Description of Proposed
Work:___________________________________________________________________________
Danielle McKahn
5/17/2017
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
Name of License Holder :___________________________________________________________
___________________________________________________________________________
Address
___________________________________________________________________________
Signature Telephone
Not Applicable !
_____________________________________
License Number
_____________________________________
Expiration Date
9. Registered Home Improvement Contractor:
__________________________________________________________________________ Company Name
__________________________________________________________________________ Address
_________________________________________________Telephone__________________
Not Applicable !
_________________________________ Registration Number
_________________________________ Expiration Date
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 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-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” 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 ________________________________________________________
X
X
X
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
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: 32 Perkins Ave, Northampton_________
The debris will be transported by: Danielle McKahn (owner)
The debris will be received by: ______________________________
Building permit number: ______________________________
Name of Permit Applicant Danielle McKahn
_________________________________________
Date Signature of Permit Applicant
Valley Regional Recycling and Transfer Facility
5/17/17
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):_________________________________________________ _
Address:__________________________________________________________________________
City/State/Zip:_____________________________ Phone #:________________________________
*Any applicant that checks box #1 must also fill 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 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 under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone #:
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 #:_________________________________
Type of project (required):
6.New construction
7.Remodeling
8.Demolition
9.Building addition
10.Electrical repairs or additions
11.Plumbing repairs or additions
12.Roof repairs
13.Other____________________
1.I am a employer with _________
employees (full and/or part-time).*
2.I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers’ comp. insurance
required.]
3.I am a homeowner doing all work
myself. [No workers’ comp.
insurance required.] †
Are you an employer? Check the appropriate box:
4.I am a general contractor and I
have hired the sub-contractors
listed on the attached sheet.
These sub-contractors have
employees and have workers’
comp. insurance.‡
5.We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, §1(4), and we have no
employees. [No workers’
comp. insurance required.]
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers’ compensation for their employees.
Pursuant to this statute, an employee is defined as “...every person in the service of another under any contract of hire,
express or implied, oral or written.”
An employer is defined as “an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.”
MGL chapter 152, §25C(6) also states that “every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.”
Additionally, MGL chapter 152, §25C(7) states “Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority.”
Applicants
Please fill out the workers’ compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers’ compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers’
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under “Job Site Address” the applicant should write “all locations in ______(city or
town).” A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department’s address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia Revised 7-2013
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ● Municipal Building
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner
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 any person(s) who seek to use the homeowner 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 beresponsible 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 permitsand inspections are made
I, __________________________________________________ understand the above.(Home owner /resident’s signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date_______________________
Address of work location_____________________________________________________
_____________________________________________________
_____________________________________________________
32 Perkins Avenue
5/17/17