30C-074 564 BURTS PIT RD BP-2017-1218
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:30C-074 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit BP-2017-1218
Project# JS-2017-002050
Est.Cost: $10345.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TODD ALEXANDER
Lot Size(sq.ft.): 33541.20 Owner: ASTOR ROBERT H&VICKI .1 GOLDLUST
Zoning: SR(lo0yWSP(100)/ Applicant: TODD ALEXANDER
AT: 564 BURTS PIT RD
Applicant Address: Phone: Insurance:
202 RESERVOIR RD (413) 652-3430 ()
W ESTHAM PTON MA01027 ISSUED ON:4/27/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD 5'TO EXISTING DECK, REPLACE DECKING
AND RAILINGS
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 4/27/2017 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
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File# BP-2017-1218 N h�
APPLICANT/CONTACT PERSON TODD ALEXANDER y'p` �.�,�
ADDRESS/PHONE 202 RESERVOIR RD WESTHAMPTON (413)652-34300 Si
PROPERTY LOCATION 564 BURTS PIT RD
MAP 30C PARCEL 074 001 ZONE SR(1001/WSP(1001/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT ION CHECKLIST
CLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building.Permit Filled out �p
Fee Paid
TyoeofConstruction: ADD 5'TO EXISTING DECK,REPLACE DECKING AND RAILINGS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO MATION 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 Be 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
�e •lii,,,elelay
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 0*
City of Northampton Status of Remit rmit
APtc Building Department CurbCut/DrivewayPermit
sewer/swat
212 Main StreetAvanabrety
L_ Room 100 wateHWell Availability
No Northampton, MA 01060 TwoSetsof SNxWralPlans
phone 413-587-1240 Fax 413-587-1272 Plotlsite Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property AtltlressThis section to be completed by office
G cf 6%.)eh
:.h /� "�pCa�� Map Xi Lot O 7% Unit
L4'.4QQ./Lc</ a k4 0�06
Zone Overlay District
Elm St.District Ce District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Vier( G01-01-o rOC„1e
Name(Pant) j Current Mailing Address:
Telephone r1 z 3 �a
Signature T
2.2 Authorized Aoent: 'I
Todd A�n� a 0 r cscrva,`r Rb into Si` s-y- M, "nil
Name(Print) Current Mailing Address:
lb Of` _ 41/3- ‘5Z-3930
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building I 0 r 345— (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 #
6. Total=(1 +2+3+4+5) /013t15- Check Number 4 f ((,,�1
This Section For Official Use Only
Building Permit Number: Date
Issued'
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING AR 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 k
(lot area minus bldg&paved
parking)
it of Parking Spaces
HII:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ® DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page and/or Document k
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW 0 YES
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 C1l
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. WII 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 4'V
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) ❑ Rooting ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [RI Siding[O] Other[0] -
Brief Description of Proposed 1
Work: lido S' -Yo Ha ex., u, O
,s� , `/c]eck I re(f4tdZ n, anti rot (1155
Alteration of existing bedroom Yes 7( No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes )C 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, VV._r_( Vt LtXu $ I , as Owner of the subject
property �^ I,.
hereby authorize 10�t�wod'rT
to action.my behalf ay rtf� rs rel tive to work authorized by this building permit ap9lication.
(�it ..� l/C• 1J 17
Signature of Owner Date
I, 7 adti Rb(grat cr , 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 the pains and penalties of perjury.
7O is A sr
Print Name
V(rd` C✓ \-- 41/7-5- ill
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:tNot Applicablea/ 0
Name of License Holder: lo(Jd '1-(k/sc./Jr G Sl3QD
License Number
O2 gcscrvpi- Kosd ue C nA oio t 7 I III Ie61(
Address Expiration Date
" 7 1413- (a S2 - 3 `130
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable 0
"1-0 i36 PR-orkmockt Le-nekt,(415 Hts 9Y(
Company Name Registration Number
spem-e f Zai(
Address Expiration Date
Telephone -S
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 a No 0
11. - Home Owner Exemation
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 imended 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: Sb`l g cts P } 643
The debris will be transported by: -rcAri
The debris will be received by: Ve((ty froyc(r,,
Building permit number:
•
Name of Permit Applicant To d 5s^r
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
__
=,-el=Et Office of Investigations
e ;_ 1 Congress Street,Suite 100
'-10�il= Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ( ' �1 L� Please Print Legibly
Name (Business/OrganizatioNlndividual): `repo ttw.n4Aot c'6nq, c t �itC
Address: Z67- kSG(Votr 126,
City/State/Zip: toeS}la'y}rn, MA aloZl Phone#: 413- (>S7- 7f30
Are you an employer? Check the appropriate box: Type of project (required):
I am a employer with I 4. 9 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. E Remodeling
ship and have no employees These sub-contractors have g, 9 Demolition
workingfor me in anycapacity. employees and have workers'
a tY. 9. 9 Building addition
[No workers' comp. insurance comp. insurance.•
required.) 5. 9 We 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.] t c. 152, §I(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t I lomeowners 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: A-T.M. f'lc4-rs.g1 /
Policy#or Self-ins. Lic. #: U C-SOD-541271 C.- Z6/T A Expiration Date: 4/ZIIr7
Job Site Address: Sc( Qt..,45 e g City/State/Zip: Von-AU,P^t1 oio42_
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 certify under the pains/ a and penalties of perjury that the information provided above is true and correct.
yy
Signature: "QO/0 (N"-- Date: 9/2-(11'7
Phone#: 913- 45-2 - 3436
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#:
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