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23A-149 (5) en-, City of Northampton "'I'l"el Building Department Plan Review t'v 1 212 Win Street Northampton,MA 01060 a r�o� ��C ��s je? i46 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su is r: // Not Applicable ❑ Name of License Holder: tle 2 / License Number YKf Alr� M CP 1V 0135"y 4-0 W`, l 7 Address Expiration Date /. - ?2, '- 3 3 Signature Telephone 9.Registered Home Improvement Contractor::-7 �J Not Applicable ❑ / % q�l Company Name / Registration Number Address Expiration Date ?, l � �J zz � Telephone J l 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 Ms 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 ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[01 Other[E31 Brief Description of Propos i t j Work: bP'� w f► trl",k5a ) 6�\P 1 Alteration of e)dsting bedroom Yes No Adding new bedroom Yes No Attached Roll -Sheet Narrative Plans Att Renovating unfinished basement Yes No Plans 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. Dimensions e. Number of stories? f. Method of heating? Fireplaces 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 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- 1. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1. 41i4g4l as Owner of the subject property v he orize to a p beha ,in all matters alive to work authorized by this building permit application. Signature of Date as Owner/Authorized Agent hereby deciarelthat 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 /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 Side L: R: L: R Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces Fill: volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DONT KNOW © YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW © YES O IF YES: enter Book Page and/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 Q Obtained O , 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 O NO 0 IF YES, describe size,type and location: E. Will the construction activity disturb(clearing,orading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit j 212 Main Street Sewer/Septic Availability AUG _ 3 Nib Room 100 Water/Well Availability, orthampton, MA 01060 Two Sets of Structural Plans L587-1240 Fax 413-587-1272 Plot/Site Plans Pt, 1 l J JEiO Other SMecff 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 Map Lot Unit Zone Overlay District Elm St District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ID a,,-� Lv�Scl \0 VACVJ� ' Name(Pn Current Making Address: Telephone rx Signature ) 2.2 Authorized Agent: Name( Current Mailing/Address: Signa Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com tact by permit applicant 1. Building Q f (a)Building Permit Fee 2. Electrical U J (b)Estimated Total Cost of r Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+4+5) t }(} Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2016-0142 APPLICANT/CONTACT PERSON ANDREW COLE ADDRESS/PHONE 469 MAIN RD GILL01354(413)325-1383 PROPERTY LOCATION 110 PINE ST MAP 23A PARCEL 149 001 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 BATHROOM New Construction Non Structural interior renovations Addition to Existing _ Accessory Structure B__uilding Plans Included: Owner/Statement or License 92165 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: �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 D olition De la 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. 110 PINE ST BP-2016-0142 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23A- 149 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-2016-0142 Project# JS-2016-000237 Est. Cost: $14000.00 Fee: $91.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ANDREW COLE 92165 Lot Size(sq. ft.): 43995.60 Owner: SAGE DANIEL Zoning. URB(100)/ Applicant: ANDREW COLE AT: 110 PINE ST Applicant Address: Phone: Insurance: 469 MAIN RD (413) 325-1383 WC G I LLMA01354 ISSUED ON:8/4/201 S 0:00:00 TO PERFORM THE FOLLOWING WORK.REMODEL 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 8/4/2015 0:00:00 $91.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner