32A-192 SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: `'t) (3 U J t� Jf rc 92-Y-1- 7 (lj
License Number
5 to 5 2 Akcv , tia 101 tt(Z t(
Address VVs r Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor Not Applicable ❑
C 6i 2 jkC WV ((42 t Z-
Company Name Registration Number
�
LCX — �- L 12- (2_z J 2-c)
Address �-{/ Expiration Date
Nb'ILL 4Acv 0 ' G,b,1 0 1 ,
11 (s v Telephone off° , ZZ
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 ❑ b(`l - - --
I1. - 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [D] Other [D]
Brief Description of Proposed
Work: \ C - ‘ TL --VegA t ( --i) P --1... /
Alteration of existing bedroom Yes V Adding new bedroom Yes 7 No
Attached Narrative Renovating unfinished basement Yes it No
Plans Attached Roll - Shee_j,2
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 O CIU
c. Is there a garage attached?
d. Proposed Square footage of new construction. C'" Dimensions ,
t
e. Number of stories? , ,Q Q
Rs
f. Method of heating? Firepla •r Wooc ves Number of each
J ti
g. Energy Conservation Compliance. \ asscheck 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 , - ow finished grade
k. Will building conform to - Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SEC 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
• ERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
J N El ' b TT E t / 1/47 (6 /be
I, , as Owner of the subject
property ��
hereby authorize 1 ( i.1/4) v-\--
to act o b half, in all m tt ela tow th • . :.:� • , ' •' •ermit ap lication.
41,4 - \-/ --1, Pi . 717 ) 1
Signature of er Date
I, I C % 'Zx-� ` j , 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 1 ( I 6 1 ( l
Signature of Owner /Agent ~ 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 by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L:l
Rear
,1
Building Height _ C
Bldg. Square Footage X.
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Sp al Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book : Page , d /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Iss ed:
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, exc tion, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
I r.. SOO
Mme' 4
� D Department use only
R�, , ity of Northampton Status of Permit
uilding Department Curb Cut/tariveway Permit
i 9 212 Main Street Seu r /Se ttcAvailabiltty
Room 100 Water/ Veil Availability
., i w,o ampton, MA 01060 Two Sets of Structural Plans , ,
,
•O `, - - , - 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
1.1 Property Address:
This section to be completed by office
4_ 2-- Q vitL- L -+. V L--v€1-t--C. Map Lot Unit
`v 00" (2' N Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Nl• -IJ c -ts co vA-Ww�) / Pd z P LA, p s P LSE / t- 6 '
Name (Pr
i r Curre ■ ailing Address:
T � l v!, - t — t -:7 u/ � - � � lephone
Signature • VVV
2.2 Authorized Agent:
1 t -(t-(' kj■, t -lc$- -- (' S V--f - C I2.4i - C v t cn8 t+'P3i
Name (P . t) 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 4 Z �0 (a) Building Permit Fee
•
2. Electrical el- ' )t). (b) Estimated
Total
Construction from (6 of
)
3. Plumbing ( S - c00 • Building Permit Fee
4. Mechanical (HVAC) '
5. Fire Protection _ Q /�
6. Total = (1 + 2 + 3 + 4 + 5) T y 7,0 C) Check Number /4 J0✓ T�i 4
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0273
APPLICANT /CONTACT PERSON ROBERT WALKER
ADDRESS/PHONE 36 Service Center NORTHAMPTON (413) 584 -1224
PROPERTY LOCATION 42 PHILLIPS PL
MAP 32A PARCEL 192 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 1/r4 4393,0
�
Fee Paid / J�J
Typeof Construction: REMODEL KITCHEN
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 034783
3 sets of Plans / Plot Plan
THE FOL OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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 Commission _ Per DPW Storm Water Management „
,,,,-
� emo �' on i = a 7-;7;77/
Signature of Build ing fficial 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.
42 PHILLIPS PL • BP- 2012 -0273
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 192 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0273
Project # JS- 2012- 000440
Est. Cost: $57200.00
Fee: $343.20 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT WALKER 034783
Lot Size(sq. ft.): 12109.68 Owner: PALOMO M FRANCISCO & JANE L POTTER
Zoning: URC(l00)/ Applicant: ROBERT WALKER
AT: 42 PHILLIPS PL
Applicant Address: Phone: Insurance:
36 Service Center (413) 584 -1224 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON: 9/26/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN
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 9/26/2011 0:00:00 $343.20
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
I IN
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