23A-144 (8) 121 PINE ST BP-2019-0618
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-Block:23A- 144 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: KITCHEN&BATH RENO BUILDING PERMIT
Permit# BP-2019-0618
Proiect# JS-2019-001015
Est.Cost: $18000.00
Fee: $117.00 PERMISSION IS HEREB Y GRANTED TO:
Const.Class: Contractor., License.
Use Group: Homeowner as Contractor
Lot Size(sa. A.): 20603.88 Owner. SIPPEL R THOMAS
Zoning:URB000)/ Applicant: SIPPEL R THOMAS
AT. 121 PINE ST
Applicant Address: Phone: Insurance:
121 PINE ST (413) 329-0690-0
FLORENCEMA01062 ISSUED ON:1/18/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-RENO BATH AND KITCHEN IN IN-LAW APT
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: QaInsulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupangy Signature:
FeeType: Date Paid: Amount:
Building 1/18/2019 0:00:00 $117.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
A Q L0, F-e- -r N\l,
filo#104019.061&
APPLICANT/CONTACT PERSON SIPPEL R THOMAS
ADDRESS/PHONE 121 PINE ST FLORENCE (413)329-0690 Q
PROPERTY LOCATION 121 PINE ST
MAP PABg9L 144 QQ I Z NE 1 /
5ECTIPN FORQEfIr.14L USE ONLY;
PERMIT APP„LICAIION CHECKLIST
NCL O D REQUIRED DATE
ZQNWG F RM FILLED gUT
e Paid
Building PgMit Filled g1g
Egg i
Tvneof Construction: RENO BATH AND T&HENIN4KLAW APT
New-Constructign
No S ctural' teri r reno a'on
Addition to Lxiging
Agce5§9a
Buil u d:
QwneL/.5%eMVtLiLfc@nse
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
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
Demolition Delay
Si ture 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 Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
' Room 100 Water/Well Availability
s 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, R AIR R SHA NE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION NOV
1.1 Property Address. Th islon to be c/omplet by office
DEPT OF 6U ,INSPOt 1 7 (�nit
/�fsVE NOHTHAMI PPTTON,MA 01060
./A4- 0106 L
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
— !;�� Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature U all Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by permit applicant
1. Building / d G (a)Building Permit Fee
2. Electrical ( / —� a (b)Estimated Total Cost of
l `7 Construction from 6
3. Plumbing /� Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Section For Official Use Only
BuildingPermit Number: Date
Issued:
Signature:
Building Commissioner/inspector of Buildings _ - Q Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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.,z _. R
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area 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 DON'T KNOW YES 0
IF YES, date issued:';
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW 0 YES Q
IF YES: enter Book Page _ and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued
C. Do any signs exist on the property? YES NO te
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q
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 0 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) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [[] Siding[p] Other[a
Brief Description of P;qposed
Work: �'- mo V-A
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
a. Use of building : One Family Two Fam" Other
b. Number of rooms in eac)ofw
unit: Number of Bathrooms _
c. Is there a garage attach
d. Proposed Square footagconstruction. Dimensions
e. Number of stories?
f. Method of heating? 1�6vCecj ✓ 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, 1�Ldwas
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 Date
I, 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.
Print Name
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
.# ealsteretl Ior»e tmtuveflitfYt Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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...... ❑
City of Northampton
'
' Massachusetts s
�� 4l';
DEPARTMMT OF BUXLDING INSPECTIONS
212 Matin Street • Municipal Building >�
Northampton, MA 01060 �s`�.�• _��� `
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered
Type of Work: 2ee,(o UG 7�/` �� �'; r� ��� Est. Cost:
Address of Work:
Date of Permit Application:
1 hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
Job under$1,000.00
Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L. Chapter 142A. SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the abo otice, I hereby apply for a building permit as the owner of the above property:
�- Date Owner Name and Signature
City of Northampton
s �•" Massachusetts
DEPARTI-NT OF BUILDING INSPECTIONS x
212 Main Street • Municipal Building
Northampton, MA 01060 srNyy -l�`�
Massachusetts Residential Building Code
Section 110.R5.1.2
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.
Section 110.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
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 Commonwealth of Massachusetts
s. Department of Industrial Accidents
I Congress Street, Suite 100
Boston,MA 02114-2017
X' www mass.gov/dia
- Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual): d6-0 v 7Z- k Sy rlJ/.zP/
IV
Address: /tee
City/State/Zip: ,.>'/ /C�-Z Phone #: 3�'2 pVy
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with _employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3,gI am a homeowner doing all work myself.[No workers'comp.insurance required.]'
10[�Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.r-1 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees. [No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill 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'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:
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 MGL c. 152, §25A is a criminal violation punishable by 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.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 and penalties of perjury that the information provided above is true and correct.
Si afore: Date: V
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):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
�4 S '
Massachusetts ?'
DEPARThWT OF BUILDING INSPECTIONS
F 212 Main Street •Municipal Building �� a
Northampton, MA 01060
Debris 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.
The debris from construction work being performed at:
(Please print hous6 number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit 011
or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
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jAb OKunplIm Louis Hasbrouck<Iasbrouck@northamptonma.gov>
of
......... ____. ......... _.........._. ............ ................. ........... ......... ......... ......... ___....... ................. ......... .__............................____. .._._ .....__. ........... __............
121 Pine Street
1 message
Louis Hasbrouck<Iasbrouck@northamptonma.gov> Tue, Nov 27, 2018 at 6:23 PM
To: rtsippel@gmail.com
Cc: Kevin Ross<kross@northamptonma.gov>
Thomas,
I'm reviewing the building permit application for work at 121 Pine Street. I'm not exactly sure what you're proposing.
Is the house a single family,two family or 3 family?The property code calls it a 1 family,the permit application says 2 family and the
assessors have it listed as a 3 family.
Why did you include an elevation drawing?Are there going to be any changes to the exterior?
What's being demolished in the center of the"family room"? Is that the current bathroom?
Is that a chimney between the proposed toilet and sink?
Is the wall that's getting moved structural?The framing isn't shown, but the upper floor joists might be bearing on that wall (or not).
Let me know.Thanks.
Louis Hasbrouck
Building Commissioner
City of Northampton
Town of Williamsburg
(413)587-1240 office
(413)587-1272 fax
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