13-013 (2) . 33 LAUREL LN BP-2017-1260
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 13 -013 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BASEMENT RENOVATION BUILDING PERMIT
Permitil BP-2017-1260
Project# JS-2017-002105
Est.Cost: $2100.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(so.ft.): 20386.08 Owner: SKORUPSKI CHESTER I JR&CHRIS
Zoning; Applicant: SKORUPSKI CHESTER J JR & CHRIS
AT: 33 LAUREL LN
Applicant Address: Phone: Insurance:
33 LAUREL LANE
NORTHAM PTONMA01060 ISSUED ON:5/4/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:FRAME WALLS IN BASEMENT & SUSPENDED
CEILING
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 5/4/2017 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-1260
APPLICANT/CONTACT PERSON SKORUPSKI CHESTER J JR&CHRIS
•
ADDRESS/PHONE 33 LAUREL LANE NORTHAMPTON
PROPERTY LOCATION 33 LAUREL LN
MAP 13 PARCEL 013 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
CLD REQUIRED DATE
ZONING FORM FILLED OUT /
Fee Paid
Building Permit Filled out
Fee Paid
TvpeofConstruction: FRAME WALLS IN BASEcI; 2
PENDED CEILING
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
INFOR TION 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 PermitVariance'
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
a- -olition a- .y
Signaireof Building •fficial 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.
o/- Department use only
City of Northampton Statusgf Permit:
1.:#\'' Building Department Curb Cut/Driveway Penni
� �� 212 Main Street Sewer/Septic Availability
i / Room 100 Water/Well Availability
/ Northampton, MA 01060 two Sets of Structural Plans
\ // phone 413-587-1240 Fax 413-587-1272 Plol/Sne Plans
i Other SplSdfy
'/APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:I This,section to be completed by office
L ao I1— I p n! L hi%Map Lot 0I5 Unit
N Q i&&h i^CKY) P /c IV, /) /j I�-f^ Zone Ove ay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: d
J -)0?0PsK / a3 kce.L eaL Lau F. N f nI *
Name(Print) Curraen-tt MailingAddress_8-H a /
'le SddUU I
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address_
Signature Telephone
SECTION a-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building
,. /L -t u (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
/ / Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) O�
5. Fire Protection ,n�//
6. Total=(1 +2+3+4 +5) 7`V i 00( OV Check Number leo
/ This Section For Official Use Only
Building Permit Number Issu
Dated'.
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
Build i2 Department
Lot Size 151 ?cc C4itt.
Frontage C �f.... _ .
Setbacks Frontgo-o.
Side L: R: L: R:
Rear g9.c.,t
Building I?eight
Bldg. Square Footage
Open Space Footage ,a
(lot area minus bldg&prem
park me)
#of Parking Spaces
I-ill:
{volume&Isamu) - -
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW Q YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained O , Date Issued:
C. Do any signs exist on the property? YES 0 NO fit
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 Q 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 Ape -.le
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Re!istered Home Im•rovemen Contract. . Not Applicable
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.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 Affected Yes No
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owne r-occuoied 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.€ IR 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.anached 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 he 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 personas)
you hire to perform work for you under this permit.
The undersigned "homeowner'certifies and assu• • responsibility for compliance with the State Building Code,City of
Northampton Ordinances,S .. :an Local Zoni s and State of Massachusetts General Laws Annotated.
Homeowner Signature_ _ f _
— t
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition Replacement Windows Alteration(s) n Rooting n
Or Doors I]
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [I= Siding[C] Other(15:
Brief Description of Proposed \ -� _
Work. 66'Ytne ( ccLLs ,K &EVVY1ervf� 4 Sa.szAid(-4 ce ,�, I
Alteration of existing bedroom Yes No Adding new bedroom Yes No d
Attached Narrative Renovating unfinished basement viYesNo ( ,all
Plans Attached Roll -Sheet
St 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? C
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 Ta-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 on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Oate
1. A - 1 J 4 S 0 ' • a- k ( , as Owner/Authorized
Agent hereby declare that the statements and in or .tion on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Si•ned under the pains and genet f rjury. ,p
p .�e� oK �K(
Fnit9 e 1
.O„ tI • , rc DIel
Signature of Owner/Agent I Date
City of Northampton
S
Massachusetts ;ys
r � �
�.�. Itk�t S DEPARTMENT212S OF B. MDZNG lINSPECTIONSg
212 Main thao MAM1l Building ;16
Bge „ 1. Northampton, MA 01060
PEcTR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
I1OME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he/she resides or intends to be, a one or Iwo 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 home owner."
The building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation/footinas (before backfill). sonotube holes (before Dour) a rough building inspection
(before work is concealed). insulation inspection (if required)and a final building inspection
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy untillhe work canhg
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas)the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspectionss( are made
I. Cl\�`FeRSv vrOj36r h understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date -77cFI'` I x-71 C-0 2 r
Address of work lt,htion 3,/_j Lao ee L izitt4�FF
IA d�'�-he vM LJ+ l1oA.) DC
The Commonwealth of Massachusetts
a–�,.n Department of Industrial Accidents
L " —c�'!'
Office of Investigations
,m a�1_ 1= 1 Congress Street, Suite 100
�5 Boston, AIA 02114-2017
v-^f" www.mass,gov/dia
Workers Compensation I nsuranceAffidavit: BuildersContractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
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 G. ❑New construction
listed on the attached sheet. 7. 0 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. irens a comp. insurance.f 9. ❑ Budding addition
r ued.] 5. ❑ We are a corporation and its IRE Electrical repairs or additions
am a homeowner doing all work officers have exercised their 11.n Plumbing repairs or additions
right of exemption per MGL
mYSelf- [No workers comp. 12.❑ Roof repairs
insurance required.]T c. 152,§I(4),and we have no
employees [No workers 13.❑Other
comp. insurance required.]
*Arty mpicad that dleicsbox#1 must alsn fill out theariiun bdtrw dvrnrg their workers mrpmsaim pdiw infornlaion.
rlIom who submit this affidavit indicating 1 hey are doing all work and then hire outside contractors must submit a new affidavit indicatingsuch.
tContracmr�s I hat cheek this box must attached an additional sheet showing the name or the sub-contractors and sate whether or rot those emiutss have
einplo)ees. Ifthc vuhrcoMractorshaseemployeasthe/mut provldethei r workers'corp.policy number.
I am an employer that is providing workers compensation inatrance for my employee& Bdow is the policy and job Ste
information,
Insurance Company Name:
Policy#or Self-ins. Lie. IN Expiration Date:
lob Site Address: City/State/Zip:
Attach a copy of the workers compensation policy deiaration page(Siowing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGI.c. 152 can lead to the imposition o fcriminal penalties ora
fine up to SI.500.00 and/or one-year imprisonment, as well as civil penalties in the form ofa 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 crt p,{tryder the pains. • penalties of perjury that the information provided above is true and correct.
. n. I j`
nalgrt: UV`^'ham' –.i D:dcQal e701 __.
Phone P: Jko s_45-81 —r_ Z -_-
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#:
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: a3 Lav(_PL L] JF aioOD60
The debris will be transported by: O ) PJ to
The debris will be received by: L0 d- s L(
Building permit number: /� /�
Name of Permit Applicant l_ �RI'S 5t"` (13sC1i
Da - Signature of Permit Applicant
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