32A-023 (2) II CHERRY ST BP-2017-0369
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32A-023 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit it BP-2017-0369
ProjectJS-2017-000612
Est.Cost: $6200.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ROBERT GOULD 90940
Lot Size(sq.ft.): 7274.52 Owner: EDWARDS DANIEL
Zoning: URC(100)/ Applicant: ROBERT GOULD
AT: 11 CHERRY ST
Applicant Address: Phone: Insurance:
62 LYMAN ST (413) 531-1391
G RAN BYMA01033 ISSUED ON:9/20/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP AND REPLACE RUBBER ROOFING OVER
THE BATHROOM & SIDE BEDROOM. SHINGLE OVER THE FRONT PORCH ONE LAYER -4 SOS
1ST FLOOR
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 9/20/2016 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File d BP-2017-0369
APPLICANT/CONTACT PERSON ROBERT GOULD
ADDRESS/PHONE 62 LYMAN ST GRANBY (413)531-1391
PROPERTY LOCATION 11 CHERRY ST
MAP 32A PARCEL 023 001 ZONE URC(I00)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLEQ 0k(D �q
Fee Paid /�Fv��f. (� �(}, u
Building Permit Filled out
Fee Paid
Tyueof Construction: STRIP AND REPLACE RUBBER ROOFING OVER THE BATHROOM&SIDE
BEDROOM.SHINGLE OVER THE FRONT PORCH ONE LAYER-4 SOS 1ST FLOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 90940
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
De in IS
400,01:
Signature of Buildi O' trial 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.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Procell Address: // ,/ / This section to be completed by office
(^
Map Lot Unit
Zone Overlay District
Elm St.District 6B District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 41/
•-)/
/ \ /0 &7/
Ct.Q ivr R �5. 'L/ ( c e (.c�2Sr ``�'C(�-. .>: �'i✓ A
Name(Print) CuneM rasa
4
7 < ?b
1 Telephone
Sign: re
2.2 Authorized Agent:
.-r C-.6wr <L C_2 L��n iyrl., Sl 17��,nh A44
` • -••- r'rint) Current Mailing(Address: /010-5
s jl 1. 9)(
Signature Telephone
SECTION 3-E ' MATED 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 Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection ,y[�/ 1 4� //n
6. Total=(1 +2+3+4+5) Com, __ Check Number �y� s+' 7r%
This Section For Official Use Only
Building Permit Number Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings
Dale
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House in Addition ❑ Replacement Windows Alteration(s) I ' Roofing
Or Doom O
Accessory Bldg. ❑ Demolition 0 New Signs [U] Decks [0 Siding[0] Other[pi
Brief D@scription of Proposed �� E 41"'¢' rcerarc tubs. ret-,,.-.g e„t/ Eyy.�,r„ S,;-;--„
Work: Futons Sare..)l.— -E9.. r_ x P0,.rr . /'esker- `/Sil re-
Alteration of existing bedroom Yes ✓No Adding new bedroom Yes ,— No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ga. 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 10D 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.
I. Septic Tank_ City Sewer Private well City water Supply
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, �1„d2-S as Owner of the subject
property
hereby authorize c3a.,St C �2(1JL2Q
to act on my behalf,in all matters relative to work authorized by this building permit application.
�a � tia�Qs .t e
Signature of Owner Date
I. �I &4'1 Q ,as Owner/Authorized
Agent herethy 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.
n..r R
S • --- -I - r1 t C,
Signatureof Owner ent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder 14)h rap— C-2'90/C '[,Oi,a.�� 1{,o
License Number
Expiration Date
yl� Sar r3P,
SignaN - Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
nVl (1-2 /309)510tio
Company Name Registration Number
C-erF2)
Add ss Expiration Date
71e 4 (N7-gTelephone 5,3I (34)
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 0 No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 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
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: I Larr1 -sJ
The debris will be transported by: t ,
•
The debris will be received by:
Building permit number:
Name of Permit Applicant c"--7o t C-7 tom^-o,P
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informationyt�� Please Print Legibly
Name(Business/organiration/Individual): tr/hh //''Cr1_n„ Leo ( p& rfla,lts�nJ:
C 7
Address: , oL L - a,
City/State/Zip: dr,„. •
a. • _ _ Phone#: ' I. _ I
Are you an employer?Check t • appropriate box: Type of project(required):
I.❑ 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
2.10 I am a sole proprietor or partner- on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
workingfor me in anycapacity. employees and have workers'
9. Building addition
[No workers' comp. insurance comp. insurance.•
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 I1.❑Plumbing repairs or additions
myself. (No workers' comp. right of exemption per MGL
12.171 Roof repairs
insurance required.]' c. 152,§I(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that cheeks box#I must also lB out section below showing their workers'compensation policy information.
homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tcontractors that ch.k this Mn must attached an additional sheet showing the name of the sub-contactors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp_policy number_
lam 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 MOL 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 'lyy the • ins penalties of perjury that the information provided above is true and correct
v' Z l(�
Signature: Date. 9 1�__ .
i
Phone#:
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):
I.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#: