31A-239 49 KENSINGTON AVE BP-2017-1117
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31 A-239 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Porch Repair BUILDING PERMIT
Permit# BP-2017-1117
Project# JS-2017-001901
Est.Cost: $9046.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MICHAEL PHILLIPS 171266
Lot Siee(sq. ft.): 5140.08 Owner: LARKIN DIANA WOLFE
Zoning: URB(I00)/ Applicant: MICHAEL PHILLIPS
AT: 49 KENSINGTON AVE
Applicant Address: Phone: Insurance:
POBOX 514 (413) 250-79900
GOSHEN MA01032 ISSUED ON:4/6/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR PORCH ROOF/SHEET ROCK REPAIR -
REPLACE WINDOWS AND 1 DOOR
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 4/6/2017 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File'#BP-2017-1117
APPLICANT/CONTACT PERSON MICHAEL PHILLIPS
ADDRESS/PHONE P O BOX 514 GOSHEN (413)250-7990 0
PROPERTY LOCATION 49 KENSINGTON AVE
MAP 3IA PARCEL 239 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
(ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid ix*Building Permit Filled out i( /
Fee Paid
Typeof Construction: REPAIR PORCH ROOF/SHEET ROCK REPAIR-REPLACE WINDOWS AND I DOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 171266
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
0"----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 I)PW 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
evil.it .' Delay
,...„,z
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.
Department use only
City of Northampton Status of Permit:
Building DeStreet SmbOStmrAvail Pility
212 Main Street Sewer/Septic Availability
6 Room 100 Wate WeB 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 Pro Address: 1-,�` '/t y 2 3 This�1section to be completed by office
KiCSC-$ Map �//d Lot 4 Unit
�✓ ry " Zone Overlay District
N OVA-19._11-4_ 0 1t\ Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
e-0 } V L V:h
Name Print)
( Current Mailing Address:
ca
Telephone
Signature
2�.2 Authorized A ent:
Aec4=l (;PS yn� �i c)`3��c 51 � 60 \\(,(\ (*3n--
Name(Print) Current Mailing Address:
'� 1.13-`aSc ) - 79 0
Signatre Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 3rD t)'[OC/ 15((' (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 n (�
6. Total=(1 +2+3+4+5) 9/ Check Number hi` OGS
This Section For Official Use Only
Building Permit Number: Date
Issued:
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
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot arca minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW ® YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW O 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 el
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:
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? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing }
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [C] Decks [D Siding[C] Other[C]
WickDescription of Proposedi� Qfl r C /c1 Qe vo4 ^ cA�n � w�Q 5 1... ..3:4?__
Alteration of existing bedroom {. Yes /., (Noo Adding new bedroom `\F/-`Y Yes (5C No
Attached Narrative I Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. 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 100 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 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ,as Owner of the subject
property
hereby authorize
to act onhah matters relativ wo authorized by this building permit application
ignature o Owner `1A n ,r `` I �'^J IA Date
I, y�.A N1/( �\.` I I S `j c . 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 th pains and pe :'sof perju
f\n - (itut
� lS
Print N me 1
Signature of Owner/Agent Date a .-A-2
SECTION 8-CONSTRUCTION SERVICES
$.1 Licensed Construction Su•ervis• : ,`,./�`/ Not Applicable�pl/ 0
•
)4ama of License tinnier: V '_ t . .' 4r r+ l ._ t 5 U G%
License Number
41z
Addrest� 4; 1. .� 3 OS 0 l fc/0 Expiration Date
Signa re Telephone
A.Registered Home ywrwit Contractor: Not Applicable ❑
' ttips c
m � 3a
Coany Na � Registration Nurnoer
� mc\ ,&-;an St ,&-;an \Pit()(r h Laos ?
&Wres ii(t Exptra Date
1 a Telephone
/ I
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MGI.C.152,§ZSC(S))
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 IA` No 0
11. — Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellines 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 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 shell 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: if 3 Lel G.( 1M.�, N 1 '1j3f 1 , "q4The debris will be transported by: —A, )i P 51ep ,1\
(
The debris will be received by: ) Ir-\ ltC-1 R .eC.54 cti
Building permit number
1
Name of Permit Applicant M ,(\heD- 1 )(k 3►j MG.
r "L7 C
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
_a Department of Industrial Accidents
Jit_-= /
="1Ph�
Office of Investigations
t el- 1 Congress Street, Suite 100
* 'Ii�— Boston,MA 02114-2017
- www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ^'yr Please Print Legibly
Name (Business/Organization/Individual): f •�1\44_,X. •1(, }Q f _
Address:
City/State/Zip: �� OA0"35t� • ''7 Phone#: -lJ Vr ( d
Are you an employer? Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and 1
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
listed on the attached sheet. 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.t 9. ❑ Building addition
required.] 5. if ofWe are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] ' c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
'Any applicant that checks box#1 must also till out the 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.
: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: P-es LL`P' o1 !�•�p/M1/
•( Ni)Policy# I r l
or Self-ins. Lic.#: fc--J "" I \0L( Expiration Date:
` [IS do
INJ
Job Site Address: City/State/Zip: act veer k 114.431060
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 cern(,under the /
ns a�d penalties oo perjury that the information provided above isDu%c-.)
e(and correct
Sienamre: �'rV AAh!/1 Date: �1/(�( (JJyan/
Phone#: q'3 35 o-- et 0
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.CitylTown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#: