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City of Northampton
Building Department
Plan Review
212 Main Street
Northampton, MA 01060 `r
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G1 "LS FACE
GE BUILT IN ORANERS
9'-10" x 5-3"
9'-10 718"
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Building Inspector DEG -
212 Main Street _i
Northampton, MA 01060 °E ti
December 4, 2015
Dear Building Inspector,
I am writing to request that you allow the building permit that has been approved for my
house renovation at 185 Nonotuck Street in Florence be transferred from the name of my
prior contractor to the name of the new contractor who will be the person to actually do
the project. The new contractor is:
Michael Ross,
MA reg. 178457
PO Box 229
Huntington, MA 01050
phone: 413-588-6876
mrosscornerstone(.tlyahoo.com.
Thank you for your time.
Sincerely,
(6�' "-� V--t 0-/
Carol Gray
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:
� llP
The debris will be received by: �--e C� C
Building permit number:
Name of Permit Applicant i�ir/-c�' k71A�
T
Date Signature of Permit Applicant
City of Northampton
Massachusetts = _ "Siclr,
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
F f Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
n supervisor. The state defines "Homeowner"as, " Person(s) who owns a parcel on which
des or intends to be, a one or two family dwelling, attached or detached structures
o such use and/or farm structures. A person who constructs more than one home in a two-
year pero 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
lbefore 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 i
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
a understand the above.
(Home owner/reside)#YsignaYure revt Ong exemption)
I will call to schedule all required building in ion s necessary for the building permit issued to me.
Date_ l a J /
Address of work location C%'✓_\C'J_ZA,C �+.
16v-e ms D , rna C) I z
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
_. r Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information y- Please Print Legibly
Name (Business/Organization/lndividual): C o r/I'Lr`j 1 o?t e c o--rra (f(' q _`) f
Address: /�. o o f O CJ
City/State/Zip: Phone#: Lf �� (a t�-7
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.LJ 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 mein any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.$ 9. []Building addition
required.] 5. [] We area 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 12.7 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.
lHo 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.
lam an employer that isproviding workers'compensation insurance far my employees. Below is thepolicy 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 hereby cer ' nde he pains and p aloes ofperjury that the information provided above u true and correct.
Signature:_ Date:
Phone#:
Of 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 7
8.1 Licensed Const ruction/Supervisor: ( c-c Not Applicable £
Name of License Holder: 1 1)C \�Q 1 �� "� 1—7 Z —7
License Number
PO R6k ash Huy-,fi 1gfiL\, )& 010`,�b
Address J I Expiration Date
41?1- s - (&J (_
Signature Telephone
9 Reaisfered-Home:IrTiprovement.Contractor-- - Not Applicable £
Company Name Registration Number
O C) x v Nf`('A/
Address Expiration Date
TelephoneW3 76 1
SECTION 110-WORKERS.'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c..15 2 §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 uilding permit.
Signed Affidavit Attached Yes.w. £ No...... £
11 Hone Qwner.Egenpton
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 compli ce with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachus tts General Laws Annotated.
omeowner Signature. u
i
i
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all apolicabfe)
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing ❑
Or Doors M
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [M Siding [❑] Other[❑I
Brief Description of Propos d vtc P C rYCI I ts n IQ\ -R-`^C l Work:
fib L.
e e v'UUm cx--CA
Alteration of existing bedroom Yes No Adding new bedroom Yes No d C3 e Ir
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet V'i 1 ( tD
sa If New house and-an :to exlsf�ng-houslng .cornMete fF'e followlng: C 12G�(C►+',Cp dr
a. Use of building :One Family >S Two Family Other -51-M V vi
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? 1'\V
' -0 o r•=
d. Proposed Square footage of new construction.5 S Dimensions
e. Number of stories?
f. Method of-heating? CA CA 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>C No. Is construction within 100 yr. floodplain Yes e5c�" No
j. Depth of basement or cellar floor below finished grade C�6Vi(- Lv'1Vw
k. Will building conform to the Building and Zoning regulations? Yes K_No. i'1
(�r)ccm�vv",k eS will
-
I. Septic Tank City Sewer Private well City water Supply r
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR A PP LIES-FOR.BUILDING PERMIT
as Owner of the subject
property p
hereby authorize 11 C hGIL K�
to act on my behalf, in all matter relative tp work author i ed by this building permit application.
Dec ran
Signature of Owner Date
f d as Owner/Authorized
Agent hereby declare that the state ents and in 7o rillhation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
f
Si ned under t e pains and pegalti o perju
Pnnt
g ture o wne�r/g t 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:E i L:t R.- 1----( 1
Rear
Building Height (—
r
BIdg. Square Footage 1
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces 1---!
Fill:
(volume&Location)
z
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book Page # and/or Document# i
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location: f
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: j
t~
E. Will the construction activity disturb(clearing, grading, excavation,or filling)over 9 acre or is it part of a common plan
that will disturb over I acre? YES Q NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
i i
rtment use only � �(
ity of Northampton Status of Perfrtit t
uilding Department Curb CuY/Dtiuenlay F�ermit i _ '.
a'
i
212 Main Street SewerlSeptPeA?zaifa6ihty '
: r
D Room 100 INaterlVrfe7tAva�la6ility F
to ampton, MA 01060 Twa Se#soES#i�ctural Pfa[ts =
_y
- ;
E , cptt 7-1240 Fax 413-587-1272 sl?Iof/Si#e Plans "T
• :Other Specify j r, ��
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION
1.1 ProoertyAddress: This section fo be.......fed by office
Cj
Lot
1 Uvie rt Q Zone -- Overla Disfrtct'-
r
Ut U6
-- y -
SECTION 2.=PROPERTY OWNERSHIP/AUTH0RIZEDAGENT
Ly
2.1 Owner of Record: 4/TM
C CA Y
Name(Print) Current Mailing Address-
Telephone
Signature
2.2 Authorized Agent:
(Y) C 0. �2OSS �v � �� � fY1 C)losb
Nam (Print) Current Mailing Address:
6710
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
com leted by ermit applicant
1. Building (a).Building Permit Fee'
2. Electrical (b) Estimated Total Cost of
tons truct ion`fram 6
3. Plumbing -3 000 Building Per Fee 79
4. Mechanical(HVAC)
5. Fire Protection -5000 6 CAA*s—
6. Total=(1 +2+3+4+5) L{ 0 Check Number 14 0
This Section For Official`Use Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/lnspector'of Buildings: Date
File 4 BP-2016-0333
APPLICANT/CONTACT PERSON GRAY CAROL J
ADDRESS/PHONE 815 SOUTHEAST ST AMHERST01002(413)297-1075 Q
PROPERTY LOCATION 185 NONOTUCK ST
MAP 23A PARCEL 246 001 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: ADD 2ND FLR BATH. ADD BEDROOM WALL/CLOSET& IMPROVE HEAD
CLEARANCE ON STAIRWAY
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
I3uildin(T Plans Included:
Owner/Statement or License 091856
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF(?AMATION 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
Demolition Delay �J j
Signature o Building Officia 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
I'lanning& Development for more information.
185 NONOTUCK ST BP-2016-0333
GIs#: COMMONWEALTH OF MASSACHUSETTS
Ma1);_13lock: 23A -246 CITY OF NORTHAMPTON
Lot: -00 1 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-0333
Project# JS-2016-000540
Last. Cost: $9400.00
Fee: $130.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: LOUIS HALE 091856
Lot Size(sq. ft.): 9408.96 Owner: GRAY CAROL J
Zonin!: URB(100) Applicant: GRAY CAROL J
AT. 185 NONOTUCK ST
Applicant Address: Phone: Insurance:
815 SOUTH EAST ST (413) 297-1075 O WC
AM H ERSTMA01002 ISSUED ON:12171201 S 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD 2ND FLR BATH, ADD BEDROOM
WALL/CLOSET & IMPROVE HEAD CLEARANCE ON STAIRWAY - hallway must be 3' wide
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:
Ron-[): 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 12/7/2015 0:00:00 $130.00
212 Main Street, Phone(413) 587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner