38B-249 (2) SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Appliitc�a1ble ❑
Name of License Holder: L� y A 4—7
License Number
Address Expiration Date
Signature Telephone
9 Reaistered Home Improvement Contractor. Not Applicable ❑
Company Name Registration Number
S-/ 1 4--1
Address Expiration Date
Telephone �;e',P
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,1rovided 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 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: C)-- , 4- -� 9-5
License Number
til
Address Expiration Date
Signature Telephone
6.Realstered'Home Improvement Contractor: Not Applicable ❑
4^ l 1 Z0
Company Name Registration Number
Address` Expiratio Date
V\A IN- Telephoned 12 2,4
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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing El Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[
Brief Description of Proposed
Work: Co s�cl• tom -(-r- k
Alteration of existing bedroom Yes___Lf�No Adding new bedroom Yes v--1__� No
Attached Narrative Renovating unfinished basement Yes o
Plans Attached Roll -Sheet
Ga. If New house and or addition to existing housina, 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
e. Number of stories?
f. Method of heating? F' laces 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 liar floor below finished grade
k. Will build' conform to the Building and Zoning regulations? Yes No.
I. ptic 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, "]'r1P,-r`'t� 1 V, t_11F 1C as Owner of the subject
property
hereby authorize 7c"931c. -X w
to act on my behalf, in all maters relative to 1�qrk authorized by this building permit application.
Signature of Owner Date
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.
l-C
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 fille by
Building Departme
Lot Size
Frontage
Setbacks Front �
Side L: - R: L:
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking S es
Fil
plume&Location)
A. Has a Spec' t Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW 0 YES
IF YES, date issued:'`..
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW YES
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 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, excavafion, 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.
(�epartrnertt ttse I
• � City of Northampton tts of Farmlt
Building Department urb Ctttf( y Permit
212 Main Street Seuvsr �pttcAt �f
Room 100 Water/1 fell.AyaifabrlltyA
Northampton, MA 01060 of ttliotaral Plans
PU
- on 413-587-1240 Fax 413-587-1272 Plotlst , a
e' ify "" y
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
2- '> 9—: T- Map 39,& Lot_�— Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
-ro f}N N f-1Q__ J Zol /A t S►`+j F A (LV f u}-
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authori ed Agent: �i
�t;Q�i�r,Q�t 1Pcc.l� J�o (2-�l
Name(Print) Current Mailing Address:
VLA LA 13 ' 37b4 lZL- 4
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building C. (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) $ O t3 Check Number
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0514
APPLICANT/CONTACT PERSON ROBERT WALKER
ADDRESS/PHONE 36 Service Center NORTHAMPTON01060(413)584-1224
PROPERTY LOCATION 23 OLIVE ST
MAP 38B PARCEL 249 001 ZONE URB000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out y
Fee Paid
Typeof Construction: REPAIR PORCH&RESI L T REAR 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
THE FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
o ' ' n elay
/d ld s
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.
23 OLIVE ST BP-2016-0514
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B -249 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-2016-0514
Project# JS-2016-000857
Est. Cost: $25000.00
Fee: $163.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT WALKER 034783
Lot Size(sq.ft.): 9801.00 Owner: TIGNER JOANN
zoning URB(100)/ Applicant: ROBERT WALKER
AT: 23 OLIVE ST
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers Compensation
NORTHAMPTON MAO 1060 ISSUED ON:1011912015 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR PORCH & RESIDE LEFT& REAR 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 10/19/2015 0:00:00 $163.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner