18C-136 (4) SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ 2
Name of License Holder: �`°0 VlVc'Z'r .ems L 'n CS of ,4 �>
License Number
Addre Expiration Date
Signature Telephone
8 Registered Home Improvement Contractor: Not Applicable ❑
2,u k
Company Name Registration Number
rtr C�e� �� titi` e / Ld 1 2c1 'k
Address Expirati n Date
✓AA6c" Telephone ?z
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§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
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 buildine 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 D
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [❑ Siding[0] Other[O]
Brief Description of Proposed
Work: moi: � 5-Et.$at: 1La Zt1-fti N, u�: iR u-i-t/ LEI
iy�r' �k1
Alteration of existing bedroom V Yes No Adding new bedroom Yes �o
Attached Narrative r- Renovating unfinished basement Yes V No
Plans Attached Roll hee�/
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other n
b. Number of rooms in each family unit: Number of Bathrooms c �v
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dime l�sion
e. Number of stories?
f. Method of heating? F' aces 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 ands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement o lar floor below finished grade
k. Will buildin onform to the Building and Zoning regulations? Yes No.
I. is Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby a thorize ( �s
to act my b If, in 7allm,,tters relativ to work authorized by this building permit application.
Z_ev
Si . ure of caner Date
l — _,as Owner/Authorized
Agent he are reby declare that the statements and information on the foregoing application 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 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 Depart t
Lot Size
Frontage
Setbacks Front
Side L R:,.,. L-.,
ti
Rear
Building Height ,,_
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking SpecZes �
Fi .
olume&Location)
A. Has a Spe ' l 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 a or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 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,ex tion,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.
_ ^ ^ t ep - nt use drily,
�'. ! WE
i '`9� _
�] City of Northampton �EsofPermlt g
D �
Building--° ding Department
ab
�E� 2 a 2014 I 212 Main StreetA1�
Room 100 11 AvailbdEty
3No hampton MA 01060 Tv+ro1 o� a/ /s 1 �1
Electri� F -n t" rt� �L 87-1240 Fax 413-587-1272
S �.Cak cr
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 / cProperty Address:
�F U j _j jV CZ Map Lot Unit
LL-7-�1+� (rT� l�� Zone Overlay District
f"% l ✓6 0 Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 ner of Record:
1-,)L-
Nam (Print) 1 Cyrrent Mailin Address:
L ) Sy- i25 >icY�cs
Telephone
,Si ature
2.2 Authorized Agent: M
Name(P' t) 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 jl S' 1 �c (a)Building Permit Fee
2. Electrical �1` �� (b)Estimated Total Cost of
S Construction from 6
3. Plumbing V Building Permit Fee
4. Mechanical(HVAC) -z
5. Fire Protection
6. Total=(1 +2+3+4+5) ; Ow • Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0903
APPLICANT/CONTACT PERSON ROBERT WALKER
ADDRESS/PHONE 36 Service Center NORTHAMPTON (413)584-1224
PROPERTY LOCATION 68 BLACKBERRY LN
MAP 18C PARCEL 136 001 ZONE URB(100V
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
Typeof Construction: CONVERT 3 SEASON ROOM TO KITCHEN KITCHEN TO PANTRY&RGH IN
BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 034783 r
3 sets of Plans/Plot Plan te CTk96,C
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
aw
pproved 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
De
i
Signature of uild g cial 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.
68 BLACKBERRY LN BP-2014-0903
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C- 136 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-2014-0903
Project# JS-2014-001564
Est. Cost: $58000.00
Fee:$348.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT WALKER 034783
Lot Size(sq. ft.): 10846.44 Owner: LIVINGSTON HEATHER
Zoning URB(100)/ Applicant: ROBERT WALKER
AT. 68 BLACKBERRY LN
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:311212014 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT 3 SEASON ROOM TO KITCHEN,
KITCHEN TO PANTRY & RGH IN BATHROOM
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 3/12/2014 0:00:00 $348.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner