18C-136 (6) SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ( l ,,�t �7 Not Applicable ❑
Name of License Holder: � t,� �. v�+''rl��'��.r< C—e, — (J '?&7 c? 5
License Number
Address —� A ,, Expiration Date
Signature Telephone
9.Registered Horne Improvement Contractor: Not Applicable ❑
1 c Ir I I `111 � �G��x, iV/1 j Z c
�
Company Name / Registration Number
3L
Address Expiration Dale
Telephone
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. - Horne 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 D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[0]
Brief De5ipription of Proposed
Work:
%1 O ri-
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. �`'`Dimensio 4-
e. Number of stories? •
f. Method of heating? F' aces or Loves 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 buildi onform to the Building and Zoning regulations? Yes No .
I. tic 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, ✓rN N as Owner of the subject
property
hereb authorize 04g�I�/�
to a on ehalf, in al matters rela,(ive to work authorized by this building permit application.
Si ature of O ner Date
1 �C� 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
Signattle 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 fille by
Building Departme
Lot Size
Frontage
Setbacks Front
i:.
Side L: R: Q L:
Rear i
Building Height
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking S ces
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 0 DON'T KNOW 0 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 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading, ex vation, 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.
h`
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
�'�G��O Room 100 r
Wate M/ell Avallabtllty
orthampton, MA 01060 Two Sets of structural Plans-
p�n9
Eye°�tW,N°` nr�cn' phone 413-587-1240 Fax 413-587-1272 Plvt(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
rJ�'�''� I i�ctZf�� L` Map Lot Unit
V1,N,iv- Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: C
1-4i'1►'i'Wrca Art-0 T-0 N
Name(Print) yCurrenCt s,Mailing�Address:
Telephone
tuig
l�W N�, h-'r c41 r✓1�'tt i ;vw4
2.2 Authorized Accent:
��t'j�z4Z� �v'lA-t,1��c�,'2 ji'c �,t1✓Iti-V�� Cr�..�'T�.I'L� Ne +�-��-W3���,vvr4
Name(Print) (� Current Mailing Address:
02j
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 Fee
l UCiv
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) 7L-%D, Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File# BP-2015-1074
APPLICANT/CONTACT PERSON ROBERT WALKER
ADDRESS/PHONE 36 Service Center NORTHAMPTON01060(413)584-1224
PROPERTY LOCATION 68 BLACKBERRY LN
MAP 18C PARCEL 136 001 ZONE URB(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REMODEL MSTR BATHROOM& 1/2 BATH, RECONFIGURE WALLS
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 E'Cj��jY/C
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO,4MATION PRESENTED:
I/J(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
Dem litio D y
Signatu Buildi g 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.
68 BLACKBERRY LN BP-2015-1074
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-2015-1074
Project# JS-2015-002030
Est.Cost: $46700.00
Fee: $280.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT WALKER 034783
Lot Size(sq. ft.): 10846.44 Owner: LINVINGSTON PATRICK&HEATHER
Zoning: URB000)/ Applicant: ROBERT WALKER
AT. 68 BLACKBERRY LN
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers Compensation
NORTHAMPTON MAO 1060 ISSUED ON.5 11112015 0:00:00
TO PERFORM THE FOLLOWING WORK.REMODEL MSTR BATHROOM & 1/2 BATH,
RECONFIGURE WALLS
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 5/11/2015 0:00:00 $280.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner