38B-314 (4) aiph
NORTHAMPTON HOUSING AUTHORITY
49 OLD SOUTH STREET
NORTHAMPTON,MA 01060
Jon Hite 413-584-4030 FAX 582-1350
Executive Director TDD 800-545-1833 ext. 188
Equal Housing Opportunity mail @hamphousing.org
June 18, 2009
Mr. Anthony Patillo, Building Inspector
212 Main Street
Northampton, MA. 01060
Dear Tony:
Attached,please find a check for$ 25.00 dollars representing the fee for an
application for a Building Permit for construction of a 12 x 24 foot shed on our property
at 143 West Street(Grace House).
This shed is being built with volunteer labor from St. John's church. Shawn Allen
and Judson Brown are coordinating the project's volunteers at St. John's. Dave Gour will
check on the project as it is being constructed.
Please contact me if you have any questions. Specifically, I'm not sure as to how
to handle the Worker's Compensation Certificate, which does not have a box for
community service projects.
Attached, is a site plan with the proposed shed's location marked in green, as well
as a sketch of the shed.
Work is expected to begin after July 1St
Trely,ite
utive Director
...
, ' •
t.)
0 4i.
R
c:L. 18/'
./... i i t
. (t
4
-.
d I c tl III c
VI
Z l'■ 6 II i
R u [7-
ti•
r IA ii. L,L IA V
I
.J
1; ;i ' l'i _
III
N
."—
1 .0
.. , Iii11 A t) d'i
-1-, a . -.. (. , r 'm
.. --Z..
1-: \I.
a ''' , •-(,1 :---: :- c: a
q .
.... , ,
. 11 , _) ,,, , W , i)
X Y,
'...5 x 'X-. s.< - -,-. 4) :r --g - 'R x ■In ---- (A
'■
>< '.., X < N A c' -- — -N
if)( 1
C __.....)
/ ) 6.3)1' ))...:, .,, (N)
v.., ,v`, If c-■ ! ,4r IN" —...... \ ".. ‘NI A ts\I \
\...., .: ..— \,.._ ...P.,...--, \•...
C
,3
,
— cr
„T---L:..--:::..:: . ::=n7":":"--------b—E--;;;-- ft..."T--::- Er- - c----\
,
I
.11N\
1 ,,i
--7- '"I '-i: 1 I
11 ' .------------j\
[
\;
-----
,i c\
;.?
iu a
6._d
_
(--
/I
•.1 I
T ,k i
.., 4i i)
, .
--...,,
6 c„,
0,1
„t-
-.4,I
0 ' 4 +. ,-) ..,”, •"--!) .9' r a 1,—
A fri_ () P., H ts
csik
1 0 0 •A A I ■\_,
,
,...,-- a ::-.
,,, / z ..
u f ( . --------' z 6 t
, ______
. \,.
<r
TA- P4
' ' 'I.14(>\1C k.,T■-C-1' .'::, --jr-A
\ -----
i_____ ____. \I
\\
(\
\ , -
_
-__\_\\‘\
_ __ _
__-
\ :
-
.■
.- . --__ ____:.,,. ____, ■ ,,,,/,/,
\ _____________z_
*
t ,
/ .,
( ,---/
E Ho6 SET
(
,,.\ L
L
,/ ,...„, .
.. ,, ,
6/ -----1----. --v-
, \ ,
FLE./.1zED
1 ,,:\:2\
TL-A9/
7 -
'5,
, \ /
2."/` FtlzEA
-
,--( , ..-----
..! /1.,:,-
/ I
- ' .1P-,
,/ ,/-1 --,:N / 4,.....,
,
\N:,..-____________-_1 r
\ - , \ 14,_ , z..- ._________4_,e4
\ , __ __ :.
A--
i--
f \ ,
( \ ?FdposEn .5 ITE t-oc.40-10 t\ . To z„,
I Z X 2,Lf t.,Z)Cob 'FRAME
-., The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
•
Boston, MA 02111
• www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): _
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a er with employer 4. FA am a general contractor and I
have hired the sub-contractors 6. ❑New construction
employees(full and/or part-time).*
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers' comp.insurance comp. insurance.$
required.]
5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work
officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill 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 narre 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
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
fire np to$1,500 nn and/or on-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 Office 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.
Signature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City of Town. PermitfLicense —
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
S.
Version1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No Q
SECTION 11 -OWNER AUTHORIZATION-TO BE,COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, JQ v� �� as Owner of the subject property
hereby authorize t'nCtW „Al..� ._ ■,._ to
act on my beh-, in all ma ers relative to work authorized by this building permit application.
Signature,6f' ner 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 „
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: .,..w. .._. — a ..
License Number
Address Expiration Date
Signature Telephone
SECTION 13 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 0 No 0
Version1.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING, MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable tiC
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
_.. Not Applicable
Company Name:
Responsible In Charge of Construction
Address._
Signature Telephone
Version1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage ._. -._,...
Setbacks Front
Side L. _..._. R. ............ L.... R:' ._._..
Rear
Building Height ^N^ 20
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved i 30 O
parking) ,...�. _ ...�,.� _..., .../�
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES ell
IF YES, date issued: .- QO11
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0.01 DONT KNOW Q YES r4
IF YES: enter Book .8 Page and/or Document#
1E......
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES .;1
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained , Date Issued: 98t
C. Do any signs exist on the property? YES Q NO ft)
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q 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 Q NO ir4
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
K
Version1.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building 1' S b.e t.
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here.
Of Proposed Work: `` C Q q `
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 1A 1 ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ � 2A 1 ❑
E Educational ❑ 2B - I ❑
F Factory ❑ F-1 ❑ F-2 ❑ r 2C 1 ❑
H High Hazard ❑ 3A ❑
^I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify .
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: . _ , Proposed Use Group: .__._ .,. .__.___ .. .......w.
Existing Hazard Index 780 CMR 34): ,,,.,_ ,__,,,. , _,_,.._,,,.,Y._. Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
1st
1st .
2nd
2nd
3
3rd
4w
4t°
Total Area(sf) Total Proposed New Construction(sf) _ _ _
71 6P
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system
Version1.7 Commercial Building Permit May 15,2000
Department use only
City of Northampton Statukciflentiit:
Ouilding Department "'-•• '
tUtbCptIDDVeltYaYre11T,
212 Main Street
Room 100 HA421;4ell Aáiaii
jUN
° 2009 N4iyrthampton, MA 01060
Two Sets of Struc ura
. ,
phone 4-13-587-1240 Fax 413-587-1 272 plot/Site
Other Specify -
APPLICATION TO CONS-TfiLier-REfl AIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
L.,—)t-s-- SA Map Lot Unit
Noz-AVicKs141:7\17,4"... Yvk Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Li% 0 18_ AP..v•c,".".",0,
,i6totv,04-‘ _
\-\f"):‘1•C' -
Name(Print) Current Mailing Address:
Alb
Signature Air Telephone
2.2 Authoriz/rent:
Name(Print) Current Mailing Address
• I yr
Signature / Telephone
SECTION 3-EST ATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ---- (a)Building Permit Fee
2. Electrical – , (b)Estimated Total Cos t of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number ce°2-5-4—
/3._ _
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
,
File#BP-2009-1079
APPLICANT/CONTACT PERSON JESSIES HOUSE C/O NORTHAMPTON HOUSING AUTHORNY
ADDRESS/PHONE 49 OLD SOUTH ST NORTHAMPTON
PROPERTY LOCATION 143 WEST ST
MAP 38B PARCEL 314 001 ZONE URC(100)//WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out igj 4,5- ara75`
Fee Paid
Typeof Construction: CONSTRUCT 288 SQ FT SHED
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 LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I RMATION 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
,__,/ ''•oc.„i,j-7.4 --------- .' 2_ .• ay
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.
41143MtStlit BP-2009-1079
GIS#: COMMONWEALTH OF MASSACHUSETTS
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-2009-1079
Project# JS-2009-001565
Est.Cost: $5114.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 69696.00 Owner: JESSIES HOUSE C/O NORTHAMPTON HOUSING AUTHORNY
Zoning:URC(100)//WP Applicant: JESSIES HOUSE C/O NORTHAMPTON HOUSING
AUTHORNY
AT: 143 WEST ST
Applicant Address: P hone: Insurance:
49 OLD SOUTH ST
NORTHAMPTONMAO1060 ISSUED ON:6/30/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 288 SQ FT 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 6/30/2009 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo