23D-201 (2) I
118 HINCKLEY ST BP-2005-0051
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D-201 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 PERMIT411
Permit# BP-2005-0051
Project# JS-2005-0069
Est.Cost: $8200.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DENIS DUGAS CONSTRUCTION 048448
Lot Size(sq.ft.): 32931.36 Owner: JANES ERICH L&MARILYN
?nnir :URs Applicant: DENIS DUGAS CONSTRUCTION
AT: 118 HINCKLEY ST
Applicant Address: Phone: Insurance:
22 GILBERT RD (413) 527-0494
SOUTHAM PTON MA01073 ISSUED ON:7/14/04 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT FINISH ROOM IN BASEMENT
Ill
INPOST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Ow Rough: Rough:b/hi c ,,/i11:_ House# Foundation:
�'i7 Driveway Final:
Final: Final: G4c,r ftip
(/T/ Rough Frame0" �--t q`0 N
Gas: Fire Department Fireplace/Chimney: /`
Rough: Oil: Insulation: K q."--fq,.c9 Li C'�
Final: Smoke: Final: 6 K l p,_a p Av �1
THIS PERMIT MAY BE REVOKED BY THE C TY OF NORTHAMPTON UPON VIOLATII OF
ANY OF ITS RULES AND REGULATIONS.
a
----1... el , ,
Certificate of v Occu anC nature:
n �' Si�
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 7/14104 0:00:00 2597 $50.00
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212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2005-0051
APPLICANT/CONTACT PERSON DENIS DUGAS CONSTRUCTION
ADDRESS/PHONE 22 GILBERT RD SOUTHAMPTON (413) 527-0494
PROPERTY LOCATION 118 HINCKLEY ST
MAP 23D PARCEL 201 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out y� ,
Fee Paid C 7 / g4-5 —
Typeof Construction: CONSTRUCT FINISH ROOM IN BASEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 048448
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
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INFO ION PRESENTED:
proved 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 'ssion
/X°C3Y
Signature of BuildingOfficial Dafe
g
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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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, RENOV �iEI LF511A Vel R FAMILY DWELLING
\Dd)
SECTION 1-SITE INFORMATION `�
UL 1 5 2004
This-section q t 'completed by office
1.1 Property Address:
// � J et
,� �Ft ,,rr��
/ /�/ /./C e la SrMap +=ot t.� / Unit
/ y {
rektCe_ D /O Zone Overlay District
Elm St.District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Elf-Lc-. /ha21/yn \ha _s //a ,ui kJ.1y —
Name(Print) Current Mailing Address:
se& - 3c,C., y
Telephone
Signature
2.2 Authorized Agent:
lJG A S 2- 2- 6i ,t-lt /Id - ;0v-l-A, i
,046.1
Name(Prin Current Mailing Address: 0/07 3
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ZOO (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 1617 05-0--
This Section For Official Use Only
Building Permit Number: hc'61 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
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
Lot Size
Fronta,e
Setbacks Front
Side L: R: L: R:
Rear
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 DONT 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 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:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
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SECTIO7NT5-itftSCRIPZT+aON2OF.PROPOSED"WORK(check ail aapl-lcable) i
".^:-^' +...,,-s.-»+-�.-w
New House 0 Addition 0 Replacement Windows Alteration(s) 0 Roofing ❑
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: coy. '� -�i vA tS lea d r(,t /N r'o ALe �f'
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Y., Yes No
Plans Attached Roll 0 - Sheet❑
6ailf _ e illid se4and or;a iblit aria a sting=Mitingr onipie: a the fo di ing:
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. Mascheck 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
aECTION OVYNER AUTHORIZATION TO BE COMPLETED WHEN
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OYYNEFS`AGENT OR CONTRACTOR APPLIES FOR'BUILDING PERMIT
I, A Cir l I l/ n V OL 1'1 e,� , as Owner of the subject property
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hereby authorize b ..,Y► I,� L( q CAS to act on
my behalf, in all matters re ative to work authrized by this building permit applicatio .
1 . „ 13 Q
Signature of Owner Dat
rbENe S LIG4 S , 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.
S, -7)064 S
Print Na7()_em,),
7- '
Signature of Owner/A ent Date
- - o
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SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : '2)t' 4 S 0 V Ole c e/8
License Number
2-2- ( / I J £ /Ly' //7ic— 0(0 7 3 /O — /lP — a o o S'
Addres T • Expiration Date
41r4 . Sot -ova y
Si nature Telephone
;Re_ s e.e® .erne rrp Foueinent'. ont acto a -- A W-A-i4: 4;*I'i.,:N-sr 1, Not Applicable 0
` ..Q J s /00 g a
Company Name Registration Number
2Z �, /k-u /t .L '4/+/`� A ( o/07 3 (o - 3 — doo t�
Address Expiration Date
—4"4r/) /411r— Telephone -S-1 7_0 Y9
SEC ION10 WOryRKERS' 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 0
-Con
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 fo;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
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o¢11tAmpt
•+% �%is'',�/�61asaachnsrfts
^- z.:: .2.2. DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal building •
Northampton, Mass. 01060 '
\ rORKER'S COMPENSATION INSURANCE A.I1irLDAVIT
I bEAvis "--D11G4S
(Iiccnsreip rmittcc) —with a principal place of business/residence at: •
2 z G, /b. - AI , a Al. 0/0 73_ (phone'-; Sol, — 44f9 y .
• (strc icity!st t ligip)
do hereby certify, under the pains and penalties of perjury, that. -
( ) I am an employer providing the followinc v orr:er`s compensation coverage for my
elnployces•working on this job:
- (Insurance: Company) - (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (I.nsuranc Company/Policy Number) (Expiration Date)
(Name of Contractor) (insurance Companv/Policv Number) (Expiration Date)
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(Name of Contractor) (Insurance Companyil'olicy Number) (Exi. ra ton Date)
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(Name of Contractor) (Insurance Company/Policy Number) (Expiation Date)
(MLidh s.d'!itioc:al tins(ifnocc:Ttr :n inchwic.-.:ct:^.::oc. ._._.:::, .,art o:cY_._(>.<)
7 x
I am a sole proprietor and have no oneworking forme.
( ) I am a home owner 1)ef7orming all the work mn self.
NOTE:plc:se be aware that dire t',ctrcow rs wro employ;ems;:3:n<.)aa:.lt^ssncS arc_r-,;G:m cr::,pate yogi:CC lixn F,e
not tnece than throe units in tt1 idt the b,--:k.uv-rr_.;w or o:the g•_:.4_3 aptartcr-sni thcctc arc no(Gmerzlly vr-:itkrtd:a tic
cztptoyes under the tvvek ra ect:;=..atico Pat;(G1.152 s 1(5)),application by a hotncotrocs for e liccu cc p'tmi:may r. 'en-e tile
legal status of an employer under the Wcvlccla Comper.,ation AcL
I unde:tared that a copy of this:tat:meet n'-y be forwertled to the DrI truome of lnrh„trid Accidents'Office of In..vanx for the
coverlet vcria=floo and that Eau=to EtCart cov:rs urdc::ecicn 25A of MGL 152 ctn Ir_d to the imposition of c."rir_1 per-allies
eoasisting of a flue of up to$1,500.00 arld'cr i-zprivcnrnc.:t of tip to are.yeer ar4 civil penalties in the form e.t.a Stc-2 Work Ord,:and e
L'rx of S 100-00 a day agaitra m- .
_ For d4=uvttettsl use only
_i _ -----._.
---/glAtdie.
pCrmit Nuutlx:r ----- ___-�
;Sap, _ I c)t I
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t,JJ .SiGnntuiu of ccnnedlic near; _ , l j:.,:-;.
*9�STCo'La =*=u
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i s 11..410
fa ASSACI11IStttlf ___DO`_
`mL`" x. DEPARTMENT OF BUILDING INSPECTIONS _ =1 /;
INSPECTOR 212 Main Street • Municipal Building 'r%y=S
,
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 supc: ,' :;or. 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)t
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 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
3 N S
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