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31A-088 (3) City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: The debris will be transported by: Th p The debris will be received by: Building permit number: Name of Permit Applicant Date Signature of Permit Applicant City of Northampton Massachusetts 4 3cl� { DEPARTMENT OF BUILDING INSPECTIONS ✓`; �' �• M 212 Main Street • Municipal Building Northampton, MA 01060 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location 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): t r MAC` Address: ps r L��A *r` /VA Q j V hone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. [] I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. (Demolition working for me in any capacity. employees and have workers' [No workers' comp, insurance comp. insurance. $ 9._CR Building addition required.] 5. R_We are a corporation and its 10.® Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.[Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.M Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13T] Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHo meowners 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. 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 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 Office of Investigations of the DIA for insurance coverage verification. af I do her y ertify and a pains �lties of perjury that the information provided a ove is ue and correct. Si atur . Date; Y/P 1)': Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/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 Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable £/ ^� Name of License Holder: C—S ��)�G�CX License Number Address `. E pirati n ate Signature Telephone -71 6o `1 .............. ........ .................. 9.Re istere Home ' rovement Contractor Not Applicable`f£ ce- C pan, Name Re st atio Number — s— / 0 i c� Address Telephone Expir ion Dee L � 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...... £ 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 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, t0 � SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ® Replacement Windows Alteration(s) Roofing '-CiN Or Doors I] Accessory Bldg. ❑ Demolition New ign 24 D i g�!] Other(I3] Brief De ri do of Propose Work: c- ' ' � " 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 exisfin housin `co "fete the followin 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 cons uction._ �f y C-) Dimensions e. Number of stories? f. Method of heating? ho r Uj�� Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction 4"P_ P_. i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes_rNo j. Depth of basement or cellar floor below finished grade ' k. Will building conform to the Building a Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORI ION-TO BE COMPLETED WHEN OWNERS AGENT OR CONT APPLIES FOR BUILDING PERMIT 1 as Owner of the subject property hereby authorize to act on my behalf ' atters relative to work authorized by this building permit pplic ion. Signature of Owner Date �atthe as Owner/Authorize d Agent reby deents and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed nder the ins and pen Ities of perjury. Pr,KtName (-�-- r 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 Department Lot Size Frontage Setbacks Front Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location IL A. Has ( P�mi�Y�am�/���ge�r�� �u� ��o the site? �� �� �� NO ��' DONTKND\Y �~� YES ��� |F YES, date iouedd IF YES: Was the permit recorded at the Registry ofDeeds? NO K � D �� IF YES: enter Book Page! and/or �� ��Document# �� B. Does the site contain a brook' body ofvvaterorwetlands? NO ��. DONTKNOVY �~� YES ��, IF YES, has permit been or need to be obtained from the Conservation Commission? Needs to beobtained � »r� Obtained �� Date Issued: �-� �_� ' C. Do any signs exist on the property? YES K ) NO Q� IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property 7 YES 0 NO 0 IF YES, describe type ' ' . E. Will the construction activity disturb(clearing, grading,excavation, or filling)over 1 acre orioit part ofa common plan ' that will disturb over 1acre? YES � ) NO 1.7~ IF YEO,then a Northampton Storm Water Management Permit from the DPW io required. ���� r Department use only ' 1 t ! City of Northampton Status of Parmrt i CurbCuTlDrive�ivay Permt# wilding Department 212 Main Street Sewer/SepticAvailabtlrty Room 100 Wate`r/IAtellAvatlablh#y R 1 2��5 Lplb ham ton MA 01060 Twa Sefs of5tructural Plans AP 2 p =r ''- phone 13- 87-1240 Fax 413-587-1272 Plot%Slfe Plars lectric, Plumbing&Gas Inspections Other Specify . or ICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION Thls secfion to be completed by office 1.1 Property Address: 1 � Map Lot Unit f�1 ��2snar� /' /t t o S J rA 0/-010 = Zone Overlay Dtsfrict !U' Elm St, District.'' CB Drstnct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: C__ A 7 Vef-i c, Name(Print) Current Mailing Addres 'l �zR l7� 2 Telephone 11 Signature 2.2 Authorized Agent: 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 j �� (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of / d Construction`from 6 3. Plumbing �/ d x Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) -� �� e� Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector'of Buildings Date o� Fo(Z- P LA YJ R.EU It W File#BP-2015-0997 ADDRESS/PHONE APPLICANT/CONTACT A LAN 1 CHERRY ST EASTHAMPTON01027(413)977-6094 PROPERTY LOCATION 17 VERNON ST MAP 31 A PARCEL 088 001 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: CONS T 2 Y(BEDRM/BATH RJ-PILLACEE PORCH W/ 13 X 14 BEDROOM&ADD 7 X 12 DECK New Construction Non Structural interior renovations Addition to Existing Accesso1y Structure Building Plans Included: Owner/Statement or License 101628 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON HIS A PL CAT (31�IjBASED ON INFORMATION PRESENTED: ,-' Approved V Additional permits required(see below) ' PLANNING BOARD PERMIT REQUI UNDER: r J TA B fit; u 350 A� Intermediate Project: f// ite Plan A /O Special Permit With Site Plan � Major Project: Site Plan A D/O Special Permit With Site Plan ZONING BOARD PERMIT REQUIRE U ER: § Finding Special Perm' Variance* Received&Recorded at egistry of Deeds Proof Enclosed Other Permits Required: _Ae6Curb Cut from DP Water Availability Sewer Availability Septic Appro Board of Health Well Water Potability Board of Health Permit m Conservation Commission Permit from CB Architecture Committee Pe it from Elm Street Commission Permit DPW Storm Water Management Demolition Delay � / , � f 4t Z 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. \ � ƒ � � ± � \ � � � � � � / �j . � > � � �< �«/� .� �< ? � ,�d��� � » §���. ��:± x: . . <yy\� ��� ���ƒ . < � ~ � ./� :v. ��p \\����\ � � � ^^ ~ � � � � � ^ . �\�\ �.�\�����a � �© �. �/� . . �` . 2 �\�� � , `�\ �&&� �����^ >\ /\ <�����z. :� =���~^~ � 1 � � .r��� �� ��I��I�Ilul��u _~� NN �I��� � a �# � �-�- ..-w :« w«.� ��: ��z ���� } ( j ^ � � . . 1 ; : � � ) : y � _����_ , } < : ° � . : . . , > � � « ) ; : » : � : : � � � ! ? � ( ( + ��a : : »« ! , � . } 2: ��/f2 } �` � � � � � : �« ; ! : ; }) : ! � � $ ( � ) . ! � , : ° : �� : : � » . �� } } � \ � ) ) \ ' ® w . �\ � ± � ; : .. �> �« � . . �a . . ; . . � � ( , .. .�� �� �, , l �„ e �,. �,f � ��.»,. ...�.,, t<. . ,�.���w,,.. �,v �r� . �. � ., m,,,-�. ' � � .r.�w�, �n�:� �.�,�w�,�x� � � j � � � a �' Existing Floor Framing 24' Existing 12' 2X8 Joists 16" o/c 16' Existing 2X8 13'8 11 Joists 20" O/C Existing 2X8 Joists 20" O/C 24' u� Font Porch Framing 103 2X10 PT 9' 2X10 PT joists anchored 16" O/C to house 1/2" Bolts T O/C 2 PLY 2X12 PT -F---- 12" sonotube grade 24"X24" footings 48" to Bottom minimum 12" Pour Wall Diagram "C" LG FT New 2 Ply 11 7/8" LVL Existing 4X6 LL�L 7 -� top plate 3 Ply 3 Ply 2X6 Post 2X6 Post MAIN FLOOR Existing BASEMENT 16"X16" Brick Pier 10' 14' Kitchen (South) Wall Double 2X6 Top Plate Red: Existing Structure 2X6 Exterior Walls "Oor I I I[ li� Double 2X6 Top Plate 2 Ply LV L 2X6 Wall 16" O/C Existing 2X8 Floor Joists 13'8" Radiant ° a.,.. New Existing 19, 8" CMU Brick/ 8"CMU Footing Existing Existing 24" Wide Basement Brick/ 48" to Bottom 8"CMU 36" Pour Structural Ridge Support Wall (Front) 2 Ply 20" LVL Closed Cell Foam Insulation (hot roof, no venting) �61 10� sus 2 Ply 9 1/2" LVL Existing 6 1/2 X 6 1/2 Beam Existing 1 1/2" thick Wall I Rill 11 U Added 2X4 New 2X 10 Floor Joists Studs 5" Dense Pack Cellulose insulation 11 11 IlTiu i ul Existing Floor Systom Structural Ridge Bearing Wall (Back) P 2 L et5 a min 3" bearing on post 2X S d 16' O/ Existin 8"X8" Beam i i 2X6 exterior walls Slab Existin 8X8 Beam 2X8 Joists New 4"Slab New foam insulation N�Lift, Existing 8"CMU 'cCo 8"CMU A � yy� 2nd Floor Plan 16' 14' m MASTER BDRM BEDROOM 3 i x 13'-1"x 13'-b" I cn 12'b" fl � ® 0' CLOSET 6'-0"x uP DRE55ING 45'-l"x 11'-4BATH 8'-2"x 11'-4" DECK 12'-b"x 22-0" 24' 1 1 m cn m LOFT 12'-2"x 14'-0" v N ° OPEN BELOW 15'-0"x 16 R LIVING AREA 1123 sq ft Foundation Plan 3'6" 3'6" 10' Porch Slab 14' in INSULATED SLAB 14' Th-- .amy load ring 91 24'wide 12"deep 1 O, 12' INSULATED SLAB 154"x 18'-4" cv GARAGE 16' o Existing PIER _ Ghimney S/G)C> Existing Full Basement m I --- --- 'I cceys G2nrO� a' 24' (V O -Up- 16' City of Northampton Building Department Main Floor Plan Review 212 Main Street Northampton, MA 01060 Q /�czT�gS�,P�e�i✓� �tGlz�E��V� 14' PORCH SLAB -� 2X8 Wall -r "r 16' BEDROOM 12'-q"x 13'-3" � O j5C b 10' 12' LIVING x 18'-7" Le. BEDROOM , 15'-1"x 11'-2" GARAGE ry11'-l"x 1 q'-2" + eaa� �a9E aa�s R as U himne —UP— LIVING i 15-2"x 23'-5" s I e 24' PORCH b 10' LIVING AREA 1563 sq ft Northampton,MA Property Detail http://www.northamptonassessor.us/noho/propertydetail.php?map_no... City of Northampton, NIA: Residential Property Record Card New Search Property Type Classification Code Reference Card 1 of 1 Parcel - Location-Zoning-Assessment Map-Block-Lot: 31A-088-001 Zoning: Assessment: Location: 17 VERNON ST Neigborhood: 11 Land: 254,300 #Living Units: 1 Deed Book: 9127 Building: 119,000 Class: R-101 Deed Page: 65 Total: 373,300 Dwelling Information Building Sketch Style: Conventional Year Built: 1900 Story Height: 1 ; b Attic: Norte Descriptor/Area 5 A:1 Fr/B Basement: Part 624 sgft Total Rooms: 6 B:1.5Fr 384 sgft Bedrooms: 2' CAR 516 sgft Full Baths: 2' D:OFP Half Baths: 0 Fr 16 sgft 1 E:1 Fr Exterior Walls: Frame 43 51s 16 24 16sgft UP Unfinished Area: 0 10 1 so 1 z 1 z F.160 sgft Ground Floor Area: , 624' 16 1F►�e 16 G:48 s 62d 48 sgft Total Living Area: 1828 1a 1a H:FUB Finished Basement Living Area: 0 X 0' 12 1.5Fr 50 sgft.. E. 384 g Basement Recreation Area: 0 X 0 4 ' 24 24 24 jgrrL_ 7 S/ Woodburning Fireplace 1 / 1 O� o4 n Stacks/Openings: , l 1s ro i o-p�° y Metal Fireplace Stacks/Openings: 0/0 s���� - 50 Heat/Central A/C: Basic' Heating System: Warm Air' Fuel Type: Gas Addition Information: Quality Grade: C Physical Condition: Average Interior/Exterior: Same Lower 1st Story 2nd Story 3rd Story Area ...... Condition/Desirability/Utility: AV Basement lone Story Frame �— F7777F624 Vacant/Dwell/Oby Status: Dwelling F—lone Story Frame Half Story Frame IF 384 Additional Features: One Story Frame F--F-516 Brick Trim: 0 X 0 F—Open Frame Porch 16 Stone Trim: 0 X 0 F—One Story Frame �— 16 Remodeling Data: Open Frame Porch F 160 Year Remodeled: 0 �Open Frame Porch 48 Kitchen Remodeled(Y/N): F Frame Utility 1 50, Bath Remodeled(Y/N): Land Data lOutbuilding Info T e Year Size 1 Size2 Grd Cond Square Foot Type Utilities l yp Qty f �� no information' 1 of2 7/14/2015 10:09 AM 17 Vernon Street ` 130.51' Green: Additional Footprint Blue: New Porches Red: Section to be Removed White: Existing Footprint 48, 43' ° Zo' Garage 12. 28' 64.22 VVF- \I C.% -rr-N r.. V. UMass Conference Services e University of Massachusetts Amherst,MA 01003 413-577-8102 Ate- w ��llG 1N- R � ; Ya 3 �- NA F� L. ai'y- V 6 14-8' '�5 LP 9�(`l v-t; l"r a Gcul q / 0 04/0 4 �Ya � eA- 0 on Y0 3 4- 1 4 P-0 cle-S a s e n.. V IOJJ lul ep p wCI M, l� ili _mss - U"Q� VL J�11 City of Northampton 212 Main Street, Northampton, MA. 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: /-7 V L ilacs, The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant �"7l Date Signature of Permit Applicant City of Northampton Massachusetts 0 '.s�r11 . p , tt IL 4 1 L �'1 DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 jsryw .s �tt� INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill), sonotube holes (before pour) a rough buildinq inspection (before work is concealed), insulation inspection (if required) and a final building inspection The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents r 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): G� �✓� GT Address: S City/State/Zip: CX ( Phone#: l3 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. F-1 New construction 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. ZWe are:a corporation and its 10. Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11;® Plumbing repairs 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 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. tHo meowners 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. 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 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 Office of Investigations of the DIA for insurance coverage verification. I do here gli !der pains n es perjury that the information provided above is true and correct. Signat ure: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/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 Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor: Not Applicable £ Name of License Holder: 4W, v Licens Number � ��� � b -� � �N, Address Ex0iiallon Date Si re Tel phone 9.Re is eyed Home Im rovement+Coritractor „ _ Not Applicable £ i 1 D � Corlipany Name \ � Registratipn Nu ber Address ExpAratloh bate L 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 the building permit. Signed Affidavit Attach Yes... ... £ No...... £ 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 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 ReplacementVyindows Alteration(s) Roofing k� Or Doors Accessory Bldg. ❑ Demolition )CSJ New Signs [lam] Decks Siding Other[0] Brief Descripdr Proposed 1 wise ` - Q ql � f '�V SO Work: � � b l� l JD"-01, h) G{t�c Alteration of existing bedroom Yes No Adding new bedroom Yes N 0JC(a�„Q_ t Attached Narrative ARenovating unfinished baseme t Yes No ✓J Ottks Plans Attached Roll -Sheet .. �. QC. saA"If New house And_or'adtl fio "to exist n housin com lete the"followin f-P '*11 a. Use of building :One Family Two Family Other /. b. Number of rooms in each family unit: 0 Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. /)n—Dimensions e. Number of stories? r f. Method of heating?h&1 km'� R S fireplace or Woodstoves�_Number of each g. Energy Conservation Compliance.. Masscheck Energy Compliance form attached? h. Type of construction r -P&5,;-+ 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 V 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 authorize 4 S I I U to act on my behalf, i atters relati a to work authorized by this building permit pplication. Signature of Ow Date ` G as Owner/Authorized Agent hereby decl at the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed n r the pain d pena ies of perjury. Print ame Signature of Owner/Age Date ~ . Section 4. ZONING Ali Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zon'in: Building Department Lot Size Frontage Setbacks Front Rear [7-71 Building Height Bldg.Square Footage Open Space Footage % (Lot area minus bldg&payed L-j #of Parking Spaces (volume&Location) A. Has a Special. Permit/Variance/R ndirjg ever been issued for/on the site? NO �~�_�/ DON7KNOVY YES «~�~� � IF YES, dateixsuedJ | IF YES. Was the permit recorded at the Re i tryofDeeds? NO �� DO YES�~� / m,u,, ����� IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water orwetlands? NO 0 D0N7 KNOW 0 YES 0 IF YES, has a permit been or need tobe obtained from the Conservation Commission? Needs tobeobtained �-� Obtained «-� Date��� ' . C. Do any signs exist on the property? YES K 3 NO ' IF YES, describe size' type and location: D. Are there any proposed changes toor additions 0 NO IF YES, describe type / ' ' . ................... -_____..__-_-__--� E Will the construction activity disturb(clearing,grading, on.or filling)over 1 acre orisit part ofa common plan ' that will disturb over 1acre? YES NO ~fk IF YES,then o Northampton Storm Water Management Permit from the DPW ia required. �� \ r' w `53epartment use only .r r C i\ Q i Z �tr 'City oNR ampton 5#atuslofPermt Q s 0.tr � ,. Q artment Ot�ria ut/Dritewa�rPelrrtl# ,$' x I /y1 ain Street SeWerlSepticAVa�ta6Irty x ,i itn Room 100 vlater/wellAvallafjihty Northampton, MA 01060 Twa Se#s c�i Strtrctr;ral"Plans' ' one 413-587-1240 Fax 413-587-1272 Pio#/SiYe Plans , 'I`�PL{ � T' L 1 OUler+5�ecis 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 : completed by office Map Lot Umt , C� Zone ` Overlay bistr►ct , Elm.St a:DStnct-_ CB..Distuct SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: a I(��4m_ A 23 1196 Q5 oj- Name(Print) Current iling dle2. Z �`/ 7 / Telepho Signature 2.2 Authorized A ent• I 1 (� f\� c ,,\/ l I 46N r,,4 w er^ ok Na ri C ent M iling Ad ress: Si ature 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 6 c3 v 2. Electrical / (b)Estimated Total Cost of / Construction from 6 / 3. Plumbing ) 0 d Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection �'` o 0 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: _ Building Commissioner/Inspector of Buildings Date File#BP-2015-0997 0 C-b� APPLICANT/CONTACT PERSON HANS DALHANS ADDRESS/PHONE 11 CHERRY ST EASTHAMPTON01027(413)977-6094 PROPERTY LOCATION 17 VERNON ST MAP 31A PARCEL 088 001 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 /U-10k Vlov Fee Paid Typeof Construction: ADD&REMOVE BUILDING SECTIONS,ADD NEW ATT GARAGE,2 BEDRM,BATH,DECK(INCREASE FOOTPRINT 1,210 SO FT) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 101628 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN' F�RMATION PRESENTED: �j 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 ay f 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. 17 VERNON ST BP-2015-0997 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A-088 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ADDITION BUILDING PERMIT Permit# BP-2015-0997 Project# JS-2015-001917 Est. Cost: $150000.00 Fee: $965.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group HANS DALHANS 101628 Lot Size(sq. ft.): 16552.80 Owner: ALPER GLEN Zoning URB(100)/ Applicant. HANS DALHANS AT: 17 VERNON ST Applicant Address: Phone: Insurance: 11 CHERRY ST (413) 977-6094 EASTHAMPTON MAO 1027 ISSUED ON.712412015 0:00:00 TO PERFORM THE FOLLOWING WORK.-ADD & REMOVE BUILDING SECTIONS, ADD NEW ATT GARAGE, 2 BEDRM,BATH, DECK (INCREASE FOOTPRINT 1,210 SQ FT) 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 7/24/2015 0:00:00 $965.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 17 VERNON ST BP-2015-0997 GIS#: COMMONWEALTH OF MASSACHUSETTS Ma :Block: 31A-088 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:ADDITION BUILDING PERMIT Permit# BP-2015-0997 Project# JS-2015-001917 Est. Cost: $150000.00 Fee: $965.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HANS DALHANS 101628 Lot Size(sq. ft.): 16552.80 Owner: ALPER GLEN zoning. URB(100)/ Applicant. HANS DALHANS AT. 17 VERNON ST Applicant Address: Phone: Insurance: 11 CHERRY ST (413) 977-6094 EASTHAMPTON MAO 1027 ISSUED ON.712412015 0:00:00 TO PERFORM THE FOLLOWING WORK.-ADD & REMOVE BUILDING SECTIONS, ADD NEW ATT GARAGE, 2 BEDRM,BATH, DECK (INCREASE FOOTPRINT 1,210 SQ FT) 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 7/24/2015 0:00:00 $965.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner