43-022 e
1�II,I; R, ,., 3
BP- 2010 -0897
GIs #: COMMONWEALTH OF MASSACHUSETTS
lck: 43 -022 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-2010-0897
Project # JS- 2010 - 001328
Est. Cost: $3470.00
Fee: $32.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 90866.16 Owner: GAGNON DANIEL E & JULIET L
Zoning: SR(100) //WSP II Applicant GAGNON DANIEL E & JULIET L
AT. 486 PARK HILL RD
Applicant Address: Phone: Insurance:
486 PARK HILL RD (413) 586 -3483 O
FLORENCEMA01062 ISSUED ON :411612010 0:00:00
TO PERFORM THE FOLLOWING WORK: ERECT 10 X 16 SHED
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 4/16/2010 0:00:00 $32.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -0897
APPLICANT /CONTACT PERSON GAGNON DANIEL E & JULIET L
ADDRESS/PHONE 486 PARK HILL RD FLORENCE (413) 586 -3483 Q
PROPERTY LOCATION 486 PARK HILL RD
MAP 43 PARCEL 022 001 ZONE SR(100) //WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 00A a Q:4
Fee Paid
Typeof Construction: ERECT 10 X 16 SHED
New Construction
Non Structural interior renovations
Addition to Existin
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF "MATION 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 Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Building Official Date
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.
City of Northampton
Building Department
212 Main Street'
111 Room 100
Northampton, MA 01060
phone. 413 -587 -1240 Fax 413 - 587 -1272
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
RA �J
4 RA`r'K ALA RboA Map Lot ' Unit
OYrY�C:� r ' i U Zone, O' eria Distri
Elrii Dtsti3ct CB District
SECTION -2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
teed �hoir\ Fa& WI QA �Iorevtc ,Nth dloia
Name (Print) Current Mailing Address:
S�(v -;3`t3
Telephone
Signature
2.2 Authorized Aaent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building - (a) Building Permit' Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit l=ee
4. Mechanical (HVAC) _
5. Fire Protection
6. Total = 0 + 2 + 3 +4 + 5) 3 y -7 (, Check Number
This Section For Official Use Onl
- .Date
Building'' Permit Number: 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 G ct cs
Frontage I
Setbacks Front
f
Side L: R : ;_._.__.__l L• 1 =0 R: i_. _G i?
Rear �S
Building Height
Bldg. Square Footage % =60 ---- i—
Open Space Footage %
(Lot area minus bldg & paved
_par
# of Parking Spaces --
Fill:
volume & L.ocatlon --- --�
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO W DONT KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 r YES 0
IF YES: enter Book� j Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO W DONT KNOW Q 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 0 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 Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg.] Demolition ❑ New Signs [m] Decks [Q Siding [tom] Other [p]
Brief Description of Proposed Q /
Work: �e 1-�' P re- assembled ciccesso' -y ���p - --
Alteration of existing bedroom Yes x No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6g. lf��'1';�Bkl B� (OT1,�JCI��ttlt'�S��I ;:,CQ�C�� ��1L.�'QltxWlttq:
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.
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'.
1, D ✓E i t`1\ WA 14 Ot'\— as Owner of the subject
property
hereby authorize
to act n my bghalf, ma matters relative to work a thorized by this building permit application.
d
Signature of Owrl6r ate
l 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 pedury.
Print Name
Signature of Owner /Agent Date
SECTION 8 - CONSTRUCTION''SERVICES
8.1 Licensed Construction Supervisor �( Not Applicable ❑
Name of License Holder ht) J•r'ei,.S X, r C S 1 E- 1
License Number
a9 �,� R�. }fin- ►�,��.�. /n/q o oso $ - 3 - c? o
Address Expiration Date
Y /3 - 5 e) - -7 I -7 I
Signature Telephone
..:,
S Re[ iisttire (fotxi(E4rttg t ettfonlIptoJ' Not Applicable ❑
S°ice ou rf-s a ( F 9 0
Comoanv Name Registration Number
Address Expiration Date
W +f` oc MA 0 1 0 8 S Telephone S (o d - 7 f
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...... ❑
z; yam,. r k 4 +a° `� ,.y Z L z
�J+
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 buildine permit.
As acting Construction Construction Suyervisor 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
The Commonwealth of Massachusetts
=° x Department of Industrial Accidents
Office of Investigations
:-71
600 Washington Street
Boston, MA 02111
www. mass.gOVI&a
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Le ibly
Name ( Business /Organizationdndividual): H m et0 W n S tryct ut ( s
Address: Co U Sovfkcimp Io RA
City/State/Zip: w e 5� - I t J MA 010 B S Phone #: Li 13 a 7 1 - 7 0
Are you an employer? Check the appropriate box: Type of project (required):
I. I am a employer with S 4.E] I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6 ❑New construction
2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have g- n Demolition
working for me in any capacity. employees and have workers'
[No workers' co mp insurance comp. insurance - # 9 Building addition
required - 5 ❑ We are a corporation and its 10 Electrical repairs or additions
3. 1 am a homeowner doing ll work officers have exercised their 11- Plumbing re
g ❑ g pairs or additions
myself - [No workers' comp. right of exemption per MGL 12 (] Roof repairs
insurance required.] t c. 152, §1(4), and we have no 13.g Oth a C Ces Sow
employees. [No workers' y
comp. insurance required.]
*Any applicant that checks box #1 must also 611 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.
, 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-
1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. p
Insurance Company Name: e e k 5 k t r e _J_. —f—
n 5 u r g n (e C o m o O h v
Policy # or Self - ins. Lic. #: W C 00 q 3- , j 010 Expiration Date' S 27 a D 10
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 Off 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
. Signa : Date: 3 a 9 /
Phone #: 4 13 5 G d 7
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Perntit/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 P erson., Ph #•
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