42-077 (2) 109 GLENDALE RD BP-2017-0384
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:42-077 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-2017-0384
Project# JS-2017-000634
Est.Cost:$3000.00
Fee: $249.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BOURKE BUILDERS 055137
Lot Size(sq. ft.): 115259.76 Owner: KASKEY GARY
Zoning: Applicant: BOURKE BUILDERS
AT: 109 GLENDALE RD
Applicant Address: Phone: Insurance:
77 LONG HILL RD (413)548-9214 Workers Compensation
L E V E R E T T M A 010 54 ISSUED ON:9/23/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:FINISH PART OF BASEMENT, INSTALL SLIDING
DOOR, MOVE 2 WINDOWS TO GABLE WALL, CONSTRUCT SCREEN PORCH ON EXISTING
CONCRETE SLAB, NEW DECK
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 9/23/2016 0:00:00 $249.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0384d IC
ION/�
APPLICANT/CONTACT PERSON BOURKE BUILDERS t
ADDRESS/PHONE 77 LONG HILL RD LEVERETT (413)548-9214 p Jyw- A¢tt^UL-J
PROPERTY LOCATION 109 GLENDALE RD 1
MAP 42 PARCEL 077 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT 4
/' y/
Fee Paid CIL is /G�J -20-
Buildina Permit Filled out
Fee Paid
TvpeofConstruction: FINISH PART OF BASEMENT.INSTALL SLIDING DOOR.MOVE 2 WINDOWS TO
GABLE WALL,CONSTRUCT SCREEN PORCH ON EXISTING CONCRETE SLAB,NEW DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 055137
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
i/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 tali/Delay (�
743 090 7(
Signature of Building 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 40K Contact Office of
Planning&Development for more information.
) a " > <Department us9onlyrfy, r
City of Northampton Stents o �e j�t; " �'a`z* at ;g"
� a ilding Department t;uri4'au nvee'\4a �s �
a�- Yerm
`'� `l , za 212 Main Street ss-'1`-',.%1444".] :�' ''t ! '
C : '
,.,.-?`e Room 100 a1 IabIL .Y-ft*is - ,�3as 'u a
b� sr Northampton, MA 01060 oiStru pI ns` r'eeia'`ev s e y .,
ao ..ne 413-587-1240 Fax 413-587-1272 P .' `I,
oa .t; yE. »
A' -LI•'TION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Properly Address: This section to be completed by office
IN\ ti N-E &AO Map Lot Unit
c(o*241.3 Clei (AAA at 062_ Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
GAI`/ "Sin'? 4 No' Di Dartos- aifrsaa 109 GL ibAtt_ t7 FLoa cE 0,1a- Ctca
Name(Print) Current Mailing Address
l' At�,- Q7S- 4.343
. A ;i . ../V r Telephone
ig .tu e - '
2.2 Authorized AgelInn�t: ��
PAU.t. k . zaa.v" 77 Lo c, 1.4k.< 12Ct� L€ n 4 lcis iitit OfOiCk
Na t) Current Mailing Address:
. �.j (A . 4t3-548-gat4 -0 413-34s_o444 -c
Signature Telephone /
SECTION 3-ESTIMATED CONSTRUCTION COSTS �/+i6fr/ - /WU / CV&a rke ke,/Ckkrs.ne /
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ..- 4 (a)Building Permit Fee
23500 r &mak
2. Electricalr 4/ (b) Estimated Total Cost of
y 5`A) -- 922tC Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) O -
5. Fire Protection96/
�/ !'w
6. Total=(1 +2+3+4+5) Check Number �U / „4(it
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
,0.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House 0 Addition ® Replacement Windows Alteration(s) ® Roofing D
or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs CO Decks ® Siding CI Other[DI
Brief Description of Proposed Frn9JSk PA IV' oc Exi 51-i i. & Byds.4.ttR.n- tt.'5Tmi New -'O;oG b-»l6NElci car+6
Work: W.i4DP1.0 DQE>AfOre 4 M',ue.2- ')iN§a-05 -fa Cvolk (Jw(1. (0.-1)14L,c( 5Cr-0143 POlckt pr,)t=ytSt7C5
CoNCtICEZt$lit 6, Cot-'5Voi act 06,+1 JCC le.
Alteration of existing bedroom N. Yes No Adding new bedroom Yes K No
Attached Narrative See DE ScMQtjj Asc,;e. Renovating unfinished basement X Yes No
Plans Attached Roll -Sheet — `(e5
6a. If.New house and or addition to existing housing;complete the following:
a. Use of building : One Family 7X Two Family Other
b. Number of rooms in each family unit: b Number of Bathrooms 2
y
C. Is there a garage attached? E 5
r son,,, Pow = yZ&EE (A'- 3"X(Fi �
d. Proposed Square footage of new construction. OE<Y% 6-4 5( Dimensions 51 X 8'
e. Number of stories? t
(nvori-5pc t- HBA-t PU'^P
f. Method of heating? VS/Ofl{pe5p 177a4Ewnti-MS Fireplaces or Woodstoves N )4 Number of each
g. Energy Conservation Compliance. Nf ig Masscheck Energy Compliance form attached? N'.p
h. Type of construction t/JbOt f$.41.11A.b.
i. Is construction within 100 ft.of wetlands? Yes X No. Is construction within 100 yr. floodplain Yes x. No
j. Depth of basement or cellar floor below finished grade 7' EY-i Sto wUC
k. Will building conform to the Building and Zoning regulations? X Yes No.
I. Septic Tank 1Cs City Sewer Private well . City water Supply ye Si e-/i (,wY
5
.Eltt rti)>6
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, C I.avi t)upu G- h t$zzpvJ , as Owner of the subject
property l J�
hereby authorize PIAckl. r--pv ik ,_
to act on my be.alf, in
VIII mailers relative to work authorized by this building permit application.
Signator f n; V ~ Date e
I, ` AtA Ji:Ir- `AkAakl,- , as ft/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.
7
atx1. A. R-xxift&-
Prim Nom— /�
Vii...-&-x-2C' °onu"12i 9114)I4
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
—Cee X.c&pec Loy' PLAN)- This column to be filled in by
��ll "l l- PLAN) Building Department
n-- —_'I
Lot Size i _- i - _ _.
Frontage 1 r I [ .;
Setbacks Front --: `] 1_- J
Side L:11-111-1 R:l---J L: R:%,,,
Rear I __ '--
Building Height ____ L_ __._f
Bldg.Square Footage1---iI, —1 % 7 1
l
Open Space Footage _ _ %
(lot erre minus bldg&paved L___! _� I . L_ __;
parking)
#of Parking Spaces J 1 _ I-
Fill: _. ___�.- ____.
(volume& cation) -
Lo —_ ,. _
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:I
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book : Page and/or Document u
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW ® YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued: ` •
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO ®
IF YES, describe size, type and location:
L.
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? YEE O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 8•CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: /� Not Applicable ❑
Name of License Holder' FALtu A 13o u.oke CsFs- -o55f37
License Number
77 Lota& 14-.1 (k. t2b64-tar / cu e-6._tr� }VM e3/0„5-4 4 i(b lao(
Ad ss Expiration Dale
at�Q �c 60 Ge 4,3- 548hz4 - 0
Signature Telephone
X4( 3- 34 8t A41 —Ce
9.Recilstered Home Improvement Contractor. Not Applicable 0
-30U4A-3101_ '1A(l.0E05 LL c- (54aS
Company Name Registration Number
77 La..) 4JM . 2m. 1 U rr4.r-rr W* -Diose- 4I(b J'otA
Address l r Expiration D e
Telephone 40-50.-c(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 ❑
11e- Home Owner Exemption N/41-
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 10835.1.
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
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 -
7 a" = Office of Investigations
i MS, 1 Congress Street,Suite 100
s ttm Boston,MA021142017
�'' www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): ,16QU.kA_ t LOtr/S (.1 c
Address: 77 Ink 3Ut 14:t a, E e 04'0
City/State/Zip: 1..'eVE121Eri Mk& V J054 Phone#: 4 3 -5 40 -9 ai*
Are you an employer? Check the appropriate box: Type of project(required):
I.0 I am a employer with aj 4. 0 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. &]New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. ig Remodeling
ship and have no employees These sub-contractors have S. 0 Demolition
working for me in any capacity, employees and have workers'
comp. insurance./ 9. ® Building addition
[No workers' comp. insurance P
required] 5. Cl We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing an work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MOL y
insurance required.] r C. 152, §1(4),and we have no
I:. Roof repairs
employees. [No workers' 13.0 Other
comp.insurance required.] I
'Any applicant that checks box al must also III 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'coma policy number.
Z am an employer that its providing workers'compensation insurance for mV employees Below is the policy andjob.site
information. rr��''
Insurance Company Name: rJ5JC(4 mfN fi41diLafEJ4 - - ._. ... - A .....
Policy It or Self-ins. Lie.rt: k-542_ anc?tt -rx,IOtb k- . Expiration Date: 2 Ii. 1 t7
Job Site Address: (OS GL (t— clot4 '(-1-4044,. M/ A City/State/Zip: 0 1062
I.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 c' under thepains//and penalties of perjury that the information provided above is true and correct.
Signamle;: Ct 0 s.- - - i • . . ate: e . ....
Phone fit 2l3r5Ae- 9a-IA — O 4 5 -3A8.O 441 - C
Official use only. Do not write in this area,to be completed by thy or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.Citytfown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: „_ Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as`._every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership, association,corporation or other legal entity, or any two or more
of the foregoing engaged in a,joint enterprise, and including the legal representatives ofa deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment he deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage reclaims)."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority;'
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s) name(s), address(es)and phone number(s)along with their certificate(s) of
insurance. Limited Liability Companies((LC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage, Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly, The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please he sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy infonnation(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit_
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Depatboent's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
Tel,#617-727-4900 ext 7406 or 1-877-MASSAFE
Revised 7•2Ol3 Fax#617-727-7749
www.mass.govldia
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: to Y 0 aa a.- tetottl . clov-evCre cjx s- o obi
The debris will be transported by: t X,+i)t OtdLLe5 —riikucK1 e
The debris will be received by: c * C Pe&ycl i wG-J ci eb5ene JGr
Building permit number:
Name of Permit Applicant N‘LA-1_ A_ - 0<-0z(r.L
4 i°t/dolbCat`.(2_ n -
Date Signature of Permit Applicant
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