31A-318 H 6 VERNON ST BP-2016-1172
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 A-318 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-2016-1172
Project# JS-2016-002020
Est. Cost: $210000.00
Fee: $1365.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THAYER STREET ASSOC INC 045159
Lot Size(sq. ft.): 13982.76 Owner: MILLMAN LORAINE B
tonin : URA(100) Applicant: THAYER STREET ASSOC INC
AT: 116 VERNON ST
Applicant Address: Phone: Insurance:
8A COATES AVE (416) 665-4018 Workers Compensation
SOUTH DEERFIELDMA01373ISSUED ON:4/19/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 15 X 19 SUNROOM, ENLARGE
EXISTING BEDRM ADDITION & RENOVATE KITCHEN
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 S12nature:
FeeType: Date Paid: Amount:
Building 4/19/2016 0:00:00 $1365.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1172 Q'C�
APPLICANT/CONTACT PERSON THAYER STREET ASSOC INCjd.N
ADDRESS/PHONE 8A COATES AVE SOUTH DEERFIELD01373 (416)665-4018
PROPERTY LOCATION 116 VERNON ST
MAP 31A PARCEL 318 001 ZONE URA000Z
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid C i
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 15 X 19 SUNROOM,ENLARGE EXISTING BEDRM ADDITION&
RENOVATE KITCHEN
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 045159 ��/ ��T
3 sets of Plans/Plot Plan e "'r-
THE
GTHE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9AMATION 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
De tDe y
V�'-� '
Sign 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.
Depar#rertt pse only...:
it
Y of Northampton
-._--w----s- "� p S#atus of Permit:
uilding Department Ciirtr CutlQrivewayPerm}t.
212 Main Street Bei r/Septic Ay6ilabill't
ppR – Room 100 Watertl/yelivaitabitty ;
� No hampton, MA 01060 Twc Setsfpf° tru- raGPlans
1----- -phgrle1 - 87-1240 Fax 413-587-1272 Piot/S%ite Plans
cr .
Other Specify_
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
/I (e V P F A-00 5 f r e t Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
L- o CCG ti e_ ,1141//M a ki !& V e'r noo A 4�ah240n AA-
Narge(Print); % n ? Current Mailing Address: b 10106'0
:tu L / Tele hon / 3 s�� D
P
natur '
2.2 uthorized Agent:
11
e r etc) ol i4ar r i" 4o roajrs 14LIr- Deerr-ielcd//J/,r'. 013 13
Name ' Current Mailing Address:
lm�wv 7ACS— LLJ I I
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
—
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing ZD` oc'o - — Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+ 5) ( Check Number
This Section For Official Use Only
Building Permit Number: DateIssued:
Signature:
Building Commissioner/Inspector of Buildings 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 /Z/;_C100- 0<>, S9r f = __.
Frontage
r
Setbacks Front
Side L: "` R: L: L8-& R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
arkin )
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW (%�' YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES O
IF YES: enter Book Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtainedO Obtained O , Date Issued:
C. Do any signs exist on the property? YESa NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YESO NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YESO NO /�,Q)
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all appligable)
New House ❑ Addition Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding M] Other[�
Brief Description of Propo ed
Work:-.-44t Scan r n eA-o va /e ht 4r Aen
Alteration of existing bedroom V/ Yes No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes _L./ No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, domplete the following:
a. Use of building : One Family ✓ Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms o�
c. Is there a garage attached?
d. Proposed Square footage of new construction. s/ q f Dimensions AS
e. Number of stories? D he-
f.
e-
f. Method of heating? G 2S 1S°Ad iaV f F(cor Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. P r tScr i P i v e Masscheck Energy Compliance form attached?
h. Type of construction 4 f
j otd f i'uh► e-
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 �✓D �
k. Will building conform to the Building and Zoning regulations? !�Yes No .
I. Septic Tank City Sewer_y,," Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, L O r Q k KC 1 V ` I h'l Q 6 as Owner of the subject
property I /
hereby authorize 1/P P 11 oil /j u r r' i A A L o Vl
to(act on ^behalf, in II ers relative to work authorized by this building permit application.
'7 r
Signa re of Owner Date
I,
LIC, r h 0 N T a r r vt A 4 o 11 as /Authorized
Agent hereby declare that the statemerifs and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed rider the pains and penalties of perjury.
Print Na
� l
Signa re ofQkvj�mr/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: v e-0,('0 �ort-r n GI �o `-1 �S Dy '51S9
License Number
Pl-s (guy e b-1, AIAo/-S 72 Coq 0- )
G�/z 7�� 's - Z/6 A s Expiration Date
na ure Telephone
9. Registered Home Im rov`meet Co ractor: Not Applicable ❑
Company Name Registration Number
re e.1 A5;soc a><<� Da-►`l "1r]
Address // //�� v1373 Expiration Date
C U a 7 r S X/e DPPJ
f ,ddll4h. Telephone l//3 w4S-yo>Fr
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....... 1/ 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 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 buildling 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
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
kvi 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ' ��p i (Q ��jC�(��Q� Inc—
Address: C co S rk
City/State/Zip: ) Phone#:
Are an employer? Check the approp ' to box: Type of project(required):
1.Iff I am a employer with aO_ 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 g. ®Demolition
working for me in any capacity. employees and have workers' 9. ®Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ® 10. Electrical repairs or additions We are a corporation and its ® P
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 13.® Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners 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.#: `f �j[`1l (�(`� i Expiration Date:
Job Site Address:—// 61 Uli&6 1 1 r C_ City/State/Zip: or 4 k4 mP 'oh,194.0 1 a(o O
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 gamst the violator. Be a ed that a copy of this statement may be forwarded to the Office of
Investigations of the 1A for insur cover erification.
I do hereby c under t and p ties o ry that the information provided abov issue and correct.
Si ature: Date: � `�
Phone#: V — pl
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#•
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: //6 VCrnc)h S�-r c e4 f I0,4ka wj2�om A1q. o 10 G o
The debris will be transported by: �s � : VL S F C i/ e/C�'—5
tit U w%o 140(diA6 s
The debris will be received by: k 6 ita 's 04 6,14M
Building permit number:
Name of Permit Applicant, Vetho h 14arri hA- o
i
Date Signature of Permit Applicant