23A-196 (4) I j
' % 9
DEMO REAR ONE-STORY /
' ENCLOSED PORCH
�. -'.ADDITION OF ONE-STORY
'8UNROOM
' —DEMO COVERED PORCH %
'a+I DEMO ONE-STORY ,7p
MUSHROOM
I / �
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SITE:APPROX 21,530 SO FT SITE APPROX 21,530 80
\•\ EXISTING FOOTPRINT OF HOUSE•2,827 SO FT PROPOSED FOOTPRINT OF HOUSE-2,69180 F
EXISTING LOT COVERAGE•13.1% NEW LOT COVERAGE•12.5%
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seacOn sr LC
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EXISTING SITE PLAN r,-1 PROPOSED SITE PLAN
9/9/15 u-
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: q3 �-�
The debris will be transported by: /11
The debris will be received by: X-7
Building permit number:
Permit Name of P Applicant tic
Date Signature of Permit Applicant
City of Northampton
t �s s�.
Massachusetts X45 :_ c?lc
DEPARTMENT OF BUILDING INSPECTIONS
l" 212 Main Street • Municipal Building
Northampton, MA 01060 1ss
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)
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
x 600 Washington Street
Boston, MA 02111
µ www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le gTibly
Name (Business/Organization/Individual):
Y' a-
Address: zi -
City/State/Zip: Os�jj % /"tA" olo3 Phone #: t3
AVI:am employer? C ck the appropriate box: Type of project(required):
1. employer with 4. ❑ I am a general contractor and I
ees (full and/or part-time).
* have hired the sub-contractors 6. ❑ w construction
2. sole proprietor or pa rtner- listed on the attached sheet. 7. VRemodehng
ship and have no employees These sub-contractors have g_ ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.$ 9. ❑ Building addition
required.] 5. ❑ 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.❑ 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 PJA for insurance coverage verification.
I do hereby cer ' under a pena tl of perjury that the information provided aabTZI true and correct.
Signature: Date: -1 S-
Phone#: "((3
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#:
y
a
SECTION 8=CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: r I Not Applicable ❑ fi
Name of License Holder:
License Number
/
Address - Expiration Date I
Signature Telephone
�. - _- f-
e � d Fiomeilm uemenfGont>"aat f y� _ �<. _- Not Applicable ❑
e istration N ber
Company Name �, ,. � R 9
s w .._t
u
---I
7/
-Address / Expiration Date
-- — ( 0 Telephone
SECTION 1Q-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M GL.c,_152,§25C(6))r _
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...... ❑
n
Raw
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 1083.5.1.
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 tune,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
3
SECTION 5-DESCRIPTION OF PROPOSED WORKacheck all aaalicable) „
New House ❑ Addition Replacement Windows Alteration(s) Roofing El
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C1 Siding[ Othe [p
Brief Description of Proposed Jc
Work: 1 -
Alteration of existing bed r m Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes _XNo
Plans Attached Roll Shee
Sa if Neuv f Ouse and or adM ii ts3 existir;cl housing, irrrt�ilefe ttie=foffowi g:
a. Use of building:One Family V 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? 3
f. Method of heating? G"il—S oMassc heck or Woodstoves Number of each ' Rr If f
g. Energy Conservation Compliance. 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 4/No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and ing regulations? Yes No.
I. Septic Tank City Sewer ` Private well City water Supply ,
SECTION 7a OWNERAUTHORIZATION TO BECOMPLETED,WHEN
OWNERS AGENTOR CONTRACTOR'APPLIES FOIZBUILDINC PERMIT •..
as Owner of the subject
property
hereby authorize
to act on my behalf, in all ers r to work autholzed by this building permit application.
Signature of Owner Date
_ r
I, 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 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 1 2-11 5 S Fz i 1
Frontage
Setbacks Front
Side L:= R:�`J_..1 L: i R: !wi
Rear �
k 1j
Building Height MI
Bldg.Square Footage rt %
Open Space Footage �"'� %
(Lot area minus bldg&paved
arldn)
#of Parking Spaces
Fill: _ i
(volume&Location)
A. Has aP DON7 Special Permit/Variance/Finding ever been issued for/on the site?
NO KNOW Q YES Q
IF YES, date issued:1 ���
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book i i Pag and/or Document#I
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 0 NO
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,gradin 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.
City of Northampton 51atu � � N
SEP 82015 Department .�.,��
i uilding s Ot:it/Di t�ceaerrrit
212 Main Street r/Sep 7cyt�ratla�llrt.
Electric, Plumbing&Gas Inspections Room 100 �ater lSfE Cs�a 511rt
Northampton, A^. 1 i 060
I thampton, MA 01060 + tt St tctuial PP s i
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMAT16N:
1.1 Property Address: �- �Thrs Secfiort.fo-be corn�efed3�office�
....y fnc�-------
mI St .. t— &Distnc
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT:
2.1 Owner of Record: ri
1
Name(Print) + Current Mailing Address: j pg
Telephone
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
com le ed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical q ,h`t (b)Estimated Total Cost of
Construction from fi
3. Plumbing �-' C�� Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection U" "
6. Total=(1 +2+3+4+5) C Check Number
This-Sect ion For Official Use Onl
Date
Building Permit Number. Issued:
Signature:
Building Commissionedinspector`of Buildings . . Date
File#BP-2016-0288 �/� Q l
a
APPLICANT/CONTACT PERSON GERRY SHATTUCK ry
ADDRESS/PHONE 25 S MAIN ST HAYDENVILLE01039(413)237-9820 Q
PROPERTY LOCATION 43 BEACON ST
MAP 23A PARCEL 196 001 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: CONSTRUCT 11 X 14 SUNROOM ADDITION d
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 058422
3 sets of Plans/Plot Plan ®�
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
li ' a
9'yr.1,5
Sig of ill g i ial 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.
43 BEACON ST BP-2016-0288
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A- 196 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-2016-0288
Project# JS-2016-000476
Est.Cost: $225000.00
Fee: $1462.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GERRY SHATTUCK 058422
Lot Size(sa. ft.): 27660.60 Owner: SAALFIELD JESSICA
Zoning:URB(100) Applicant: GERRY SHATTUCK
AT. 43 BEACON ST
Applicant Address: Phone: Insurance:
25 S MAIN ST (413) 237-9820 O
HAYDENVILLEMA01039 ISSUED ON.912112015 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 11 X 14 SUNROOM ADDITION, 6 X
10 REAR PORCH, RENO KITCHEN, BATH, MUDROOM & LAUNDRY
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 9/21/2015 0:00:00 $1462.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner