Noho Residential Bldg Permit App.pdf
City 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)
_____________________________________________________
Signature
_____________________________________________________
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
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:______
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.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House
Addition
Replacement Windows
0r Doors
Alteration(s)
Roofing
Accessory Bldg.
Demolition
New Signs [ ] Decks [ ] Siding [ ] Other [ ]
_________________________________________________________________ Brief Description of Proposed
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, _______________________________________________________________________________________, 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
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 ________________________________________________________