25-078 (10)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
Rear
L: R:
L: R:
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 ® DON'T KNOW ® YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DON'T KNOW 0 YES 0
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ® , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0
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 ® NO IC)
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
Name of License Holder:
Not Applicable ❑
License Number
Address
Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor:
Not Applicable ❑
Company Name
Registration Number
Address
Telephone
Expiration Date
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.
I Signed Affidavit Attached Yes....... ❑ No...... ❑ 1
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner -occupied Dwellings of one (1) 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 Derson 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 buildine 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 a ocal Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑
Addition ❑
Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 1711
Accessory Bldg. ❑
Demolition ❑
New Signs [0] Decks [Q Siding [O] Other [E]
Brief Description of Proposed /��,,,,���.� /
Work: ?��J"RL`7 >/— �%� -1 Z/."
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 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 on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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
/
x2 Xy
ofvhler/Agent
Signa Date
SECTION 1 - SITE INFORMATION
Department use only
of Northampton
Status of Permit:
n
�✓ �u� G /
ding Department
Curb Cut/DrivewayPermit
Zone Overlay District
12 Main Street
Sewer/Septic AvailabilityROOM
Z2ampton,
100
WaterMell Availability
MA 01060
Two Sets of Structural Plans
7-1240Fax 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 Property Address:
This section to be completed by office
n
�✓ �u� G /
Map Lot Unit
/
r /` vl & A /f„ 61 S f
Zone Overlay District
1 v U✓ 'k/ 0 (v &O
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record:
/off
���LL7—I
Name (Print
1�.urrent Maung Address:
v4z ) Com^(, 7
T a —T
Telep o�i n �
SignatW
2.2 Authorized Agent:
Name (Print)
Current Mailing Address:
Signature
Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollars) to be
Official Use Only
completed by permit applicant
1. Building
(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)
Check Number
oZS
This Section For Official Use Only
Date
BuildingPermit Number:
Issued:
Signature:
Building Commissioner/Inspector of Buildings
Date
86 RIVERBANK RD BP -2012-0563
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map___Block: 25 - 078 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit # BP -2012-0563
Project # JS -2012-000951
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor., License:
Use Group: Homeowner as Contractor
Lot Size(sa. ft.): 4748.04 Owner: CITRO JOHN S
Zoning: SC(100)/ Applicant. CITRO JOHN S
AT. 86 RIVERBANK RD
Applicant Address: Phone: Insurance:
86 RIVERBANK RD (413) 268-3674 0
NORTHAMPTONMA01060 ISSUED ON:12/12/2011 0:00:00
TO PERFORM THE FOLLOWING WORK. -INSTALL PELLET STOVE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W.
Underground: Service:
Rough: Rough:
Final: Final:
Gas: Fire Department
Rough: Oil•
Final: Smoke:
Meter:
House #
Driveway Final:
Building Inspector
Footings:
Foundation:
Rough Frame:
Fireplace/Chimney:
Insulation:
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 12/12/20110:00:00 $25.00
212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272
Louis Hasbrouck — Building Commissioner