23D-145 (2) 15 WINSLOW AVE BP-2009-0858
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D- 145 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit# BP-2009-0858
Project# JS-2009-001344
Est. Cost: $4000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RONALD P MITCHELL 156186
Lot Size(sq.ft.): 16639.92 Owner: PORTER CRAIG A
Zoning: URB(100)/ Applicant: PORTER CRAIG
AT: 15 WINSLOW AVE
Applicant Address: Phone: Insurance:
11 Winslow Avenue (413) 584-8878 ()
FlorenceMA01062 ISSUED ON:4/24/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL NEW SHEATHING AND SHINGLES
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 4/24/2009 0:00:00 $50.001375
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
. ./ \
o
Department use only
City of Northampton Status of Permit
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, 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
1.1 Property Address:
/5- /1)/nSL+ 19 Map Lot Unit
,(c.Q 6)1i.CJ l 2?, ,06� Zone Overlay District
, Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of R ord:
1 6a0 ✓r /1l/)//25-6a41 iWL er e--cam
Name(Print) (, f Current Mailing AddreSrr(/) s. 7 'U78
Telephone /l
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
ompleted by permit applicant
1. Building s� jr � (a) Building Permit Fee
,/rc oe `, ii
2. Electrical (b) Estimated Total Cost of
_�� Construction from(6)
3. Plumbing Building Permit Fee
4 Mechanical(HVAC)
5. Fire Protection
6. Totai= (1 +2+3+4+5) Well) Check Number Iti37� t.5-0' 0U
This Section For Official Use Only
Date
Building Permit Number: Issued: ‘1/ tt)
Signature ‘, „0e6scr----------- 2
00
Building Commissioner/Inspector of Buildings Date
i
SECTION 8-CONSTRUCTION SERVICES I
8.1 Licensed Construction Supervisor:0/ /, �7 in
r� Not Applicable 0
Name of License Holder: t / + ?/7 'I S�
License Number
Address I Expiration Date
0 (.(4/Vg-7 - 702.3 7--
Signatur( Telephone c 3 3 l,ay
9. Registered Home.Improvement Contract`r- ri<,,, ",, '; Not Applicable 0
- fCompany Name (01ti Registration Number
Address E . ation Dates.// j
/ one /6 (Q_ (Y e e
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 0 No 0
�. tali 11 ii ,
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"cern es an a sumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State a oc • ws and State of Massachusetts General Laws Annotated.
Homeowner Signature
3
411/4
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office bf Investigations
600 Washington Street
Boston, MA 02111
a- www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/PIumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: k
City/State/Zip: Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1.Li I am a employer with ❑ 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I 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.$
required.]
5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I 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.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1Contractors that check this box must attached an additional sheet showing the nacre 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#:
•
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 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 inspections are
made
I understand the above.
(Home ow er/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date 6) •07
Address of work ) �f
location /,�'bi//)5CilA/ ol/Z