23D-187 (3) • .VAST. , BP-2004-1089
GIS#: COMMONWEALTH OF MASSACHUSETTS
tom. 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-2004-1089
Project# JS-2004-1624
Est.Cost: $3000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 8058.60 Owner: ERLANDSON MARCIE J&MYLA O'CONNOR
Zoning:URB Applicant: ERLANDSON MARCIE J & MYLA O'CONNOR
AT: 91 HINCKLEY ST
Applicant Address: Phone: Insurance:
91 HINCKLEY ST Q 585-1684 O
FLORENCEMA01062 ISSUED ON:5/10/04 0:00:00
TO PERFORM THE FOLLOWING WORK:ENLARGE EXISTING DECK
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: Receipt No: Date Paid: Check No: Amount:
Building 5/10/04 0:00:00 MO $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2004-1089
APPLICANT/CONTACT PERSON ERLANDSON MARCIE J&MYLA O'CONNOR
ADDRESS/PHONE 91 HINCKLEY ST FLORENCE ()585-1684()
PROPERTY LOCATION 91 HINCKLEY ST
MAP 23D PARCEL 187 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
A D �0 ......_
Fee Paid
Typeof Construction: ENLARGE EXISTING DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE F LLOWING 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 C 'ssion
Signature of Building Official Dat
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.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/priveway 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 413-587-127- ` ' lot/Site Plans
?ther Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
ti
SECTION 1-SITE INFORMATION
1.1 Property Address:
This section to be completed by office
i (
l i✓l c ice�le i Map r Lot / ' Unit
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Zone f / Overlay District
Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Maxi"C:1 a fir (yi Czy+ = c ct. o►1-e •
Name nnt) � �(6-nriteigiatone
Current Mailing Address:
S lure 6 [� / �+/�
2.2 Authorized Agent: V C7
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official'Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
5000
2. Electrical l(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 7/5 5-6 "
This Section For Official Use Only
Building Permit Number: &P.Og/ Or9 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
_ i
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
oa
Lot Size 77,5 , /by _
Frontage
I /
Setbacks Front £l' c 01 )÷- en
Side L: 31+' R: r L: Lb _R:627_ J S
Rear CV 2-
Building Height
Bldg. Square Footage C 76) %
Open Space Footage %
(Lot area minus bldg&paved if �
parking) _ ce /
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ` DONT KNOW YES
IF YES, date issued: I I.
IF YES: Was the permit recorded at the Registry of Deeds? N 1 0'
NO DONT KNOW YES
IF YES: enter Book Page and/or Document #
,e
B. Does the site contain a brook, body of water or wetlands? NO VV` DONT 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: 14 ;
D. Are ere any proposed changes to or additions of signs intended for the property ?YES
No r
IF YES, describe size, type and location: Hit
•
SECTIONS :DESCRIPTION-OF PROPOSED WORK(check.all applicable) '
New House 0 Addition 0 Replacement Windows Alteration(s) I Roofing 0
Or Doors 0
Accessory Bldg. 0 DemolitionD New Signs [ ] Decks [� Siding[ J Other [ J
/ 6 it
Brief Description of Proposed Work:' 'f�i� c�. �Nris "AA. icldi -c `1' Si�� 6, `4,-- ,c )
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0• Sheet 0
i5a' :f e—WM t se ancror :dditfon toe gningro g, EOThrlete l elfdliWirt:
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? ' )O
cve ex.'eK.Te 1Gz
d. Proposed Square footage of new construction. Src.,( . bimensions �' ti{
e. Number of stories?
f. Method of heating? Nf 4 Fireplaces or Woodstoves t f 4_ Number of each 10/1.4
g. Energy Conservation Compliance. A) Mascheck Energy Compliance form attached?
h. Type of construction Dt."-fitrt►ric.) +
i. Is construction within 100 ft. of wetlands? Yes i/ No. Is construction within 100 yr. floodplain Yes Nc
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
, as Owner of the subject property
hereby authorize to act or
my behalf, in all matters relative to war uthorized 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.
/V yla CbnritiK
Print Name
1 r/14 v m
Signature0 ,joy,,/a
nt Date
•
•
SECON CON •
S RUGTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder :
License Number •
Address Expiration Date
Signature Telephone
.e: ea oiri' rrror:.overeritk. ontracto - - z Not Applicable 0
Company Name Registration Number
Address Expiration Date
Telephone
gsEGTIONIO VORKERS' COMPENSATION itSuRANCE 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
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 dwell; g,attached nr detachedstnicturss accessory to_such ust_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 Zo ing Laws and State of Massachusetts General Laws Annotated.
omeowner Signatur / (t�f f
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DEPARTMENT OP BUILDING INSPECTIONS 4
za,
212 Main Street ' Municipal building
Northampton, Mass. 01060 ors•
woreCER'S COMPENSATION INSURANCE Ali ,11)AV1.T
t '
Oiccns:.Jr.crmittec)
with a principal place of business/residence at:
— —• _(hone?=)--- -- -
—
(stre t/eitt/:>'tate ip)
do hereby certify, under the pains and penalties of-perjury, that:
( ) I am an employer providing the followint worker's compensation coverage for my
employees worlang on this job:
- ("Insu-anc Company) (Policy Number) (Expiration Date) ._-
• a
•
Nl koiaa_l a sole proprietor, general contractor 0- .onheowner circle one) and have hires
the contractors listed below who have the follo-:v.t-l$ s. e s compensation policies:
(Name of Contractor) (Inrumncc Company/Policf Number) (Expiration Date)
(Name of Contractor) {7nsuranc Comptury/Policy Number) (Expir Lion Date)
(Name of Coati-actor) (Insuranec Company/?olic:Number) (Exf. rauoa Date)
(Name of Contractor) (Ins,:rance Comp✓y/Policy Number) (Expiration Date)
(attach actditienal shoot if:.-'-.^-a.^ to incl.: .. cr:r.,.ioc,: ir.:, :,i;o;c -__..,.-1
( ) I am a sole proprietor and have no one -svorking for me.
( atn a home owner performing all the work- ttt•rsclf.
NOTE:plc.ate t o ew re that wile becnoo..1r_-s..tea en-spicy pczc-s to e.)Oa r-n.race,car- -radim cr:epair",•;:_M:4....t i. of
not trtoce then throe units in tet:ie+t the b tntowoer raie:a cc o:the :13 xr•u-'-r_rtt thcao art not Ccrsally c«:::::_:r. :3 be
employes under the tvocices 0u.3�:s_:icn Act(GLI52-13 1(5)),appti=atio:by a bet•wow=fora ticm a cc p;r:tti:t:av-.',once 11Y:
legal etatuc of stn CC*loyec uotlrr the Workers Cocapar stion Act_
I un4-er taad that a copy of this etatct* taay be Iorwnreled to t✓I)1 srtnxnt of l,.vrial Ao6Lersts'Office of h_oaranoo for the
coverage vctiricatioo and that failure to rocare cover ttr3,::cc:ion 25A of}.(GI.132 can lead to the imposition of resit 1 penalties
. coasuttng of a floc of up to S I..500.00 agora in.-ttrir-x:rn of up to cr t y o:r sr.-1 civil penaltics in the roan of a Stc;,Work Or :...-.d a
rim of S 100.00 a day 1.47sn-1 err_ .
For dqustm rsal use only _ _......_
. Permit NurriYs ----_.-----_— -i
1.fap Ot.�� 1,
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'Massachusetts = _
'��''"== DEPARTMENT OF BUILDTNG INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060 .
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction super.. sor. 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)1
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 ll i
I, M��'C i z r l#. Sm- . 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. / n
Date 9- 2_1 70 q"
Address of work
location I f C S�`
.FI-0ie ;cc i pip 0 ( ac3Z
d MORTGAGE LOAN INSPECTION
LOLUS REFE2E_AICE
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