35-229 BP 16 Bayberry Ln 3-17-20Department use only
Status of Permit:
Curb Cut/Driveway Permit--------
Sewer/Septic Availability ________ _
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
Water/Well Availability _________ _
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 I
1.1 Pro~ert~ Address :
This section to be completed by office
\\p ~IA'-\ ~,{llft'1r L~I/\~ Map Lot Unit
y\.()(t ~ \.41\ f ~ ' \JV\ \A -O\.Dl.D-=> Zone Overlay District
~
Elm St. District CB District
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SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT I
2.1 Owner of Record:
:DAat~ WV\,.\.e \ u 3~~ 'r.>-e~~~
-
\ v\' 4ov-. LLA.,..-e. l) I tie~
\~am~(P)~ Current Mailing Address :
Telephone
I '5ignature
2.2 Authorized Agent:
()J "$ '4i)"' ~IA'tf "'$vwz_v,,~1<A ~~ ei::f)~-e \\u,\\~ "1)i4, o \o-:
Current Mailing Address: Na"'i!l!JZ,-fl .__Li '-l/3-5'1.o3-q;)~&,
Si~ . Telephone .
SECTION 3 -ESTIMATED CONSTRUCTION COSTS I
Item Estimated Cost (Dollars) to be Official Use Only
completed bv permit applicant
1. Building ) 3. DCO. -(a) Building Permit Fee
2 . Electrical d,"')00. -(b) Estimated Total Cost of
Construction from (6)
3. Plumbing ~\ 5'0°' -Building Permit Fee .
~-
4 . Mechanical (HVAC)
\.· -~ . -· '~ 5. Fire Protection ->
.~ ~.-t • \I, ~·
::J O. {)(J()' -
..
6 . Total = (1 + 2 + 3 + 4 + 5) Check Number l-' , .
.. .J ,.._,c ,
This Section For Official Use::'011.lv
. r ';f l' • --
Date -~ _. , !
Building Permit Number:
A . ,
Issued: -
-
Signature :
Building Commissioner/Inspector of Buildings . Date
@
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
3
' ...
1• .,•,
r·
Section 4. ZONING
Lo t Size
Fro ntaoe
Setb acks Fro nt
B uildin g He ig ht
Bld g. Squ are Footage
O pe n S pace Footage
(Lot area minus bl dg & paved
ark.i n )
# of Parki n S aces
Fill:
(volume & Location)
A.
NO
IF YES, date issued:!
All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Exi stin g
CJ
L:CJ R:r:=:J
CJ
CJ
I I
CJ
%
CJ
Proposed
CJ
Required by Zoning
T hi s colu m n to be fi ll ed in by
B uild i ng Depa rtme nt
CJ
CJ CJ
CJ
CJ
CJ
CJ
c--
ever been issued for/ on the site?
YES 0
0
IF YES : enter ......_ ___ ] and/or Document #I,__ ____ ___,
B. Does the site contain a br
IF YES, has a permit
NO O DON'T KNOW O YES 0
tained from the Conservation Commission?
0 , Date Issued : .... I ______ _,
C. NO 0
D. Are there proposed changes to or additions of signs intended for the property ? YES Q
IF YES , describe size , type and location:
NO 0
E. Will the construction activ ity 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 Q
IF YES , then a Northampton Storm Water Management Permit from the DPW is required.
~':'---.---...... ----
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SECTION 5-DESCRIPTION OF PROPOSED WORK {check all applicable)
New House D Addition Replacement Windows Alteration(s) rt;(
OrDoors Q ~ Roofing D D
D L-------------'-------------1
Accessory Bldg. D Demolition New Signs [D] Decks [D Siding [D] Other [CJ]
Brief Description off\ropo~ I ("' \ . I I .I\ ~ A ( (\ L
Work : «:('w)~J_ ~A::J B:' _ f::\.H·'-'l'l''f~ '"" "S\A\MG" ~-ttC>v'\ f-lcit.V li\uVIClrt.-a-,tO
Alteration of existing bedroom ___ Yes --A-No Adding new bedroom ___ Yes >( No
Attached Narrative Renovating unfinished basement ___ Yes R<., No
Plans Attached Roll -Sheet
Sa . If New house and or addition to existin
a. Use of building : One Family ___ _ Two Family ____ Other ____ _
b . Number of rooms in each family unit: ______ Number of Bathroo s _____ _
c. Is there a garage attached? ___ _
d. Proposed Square footage of new constructio ---------,,<------Dimensions ______________ _
h. Type of construction ______ ....,,
i. Is construction within 100 ft. of we ___ 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 AUTHORIZAT,ION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, --~--"=..:.-'-·-'t1...:::.;e"-y_,,__----'W___::__~_,_~__:::'--------------------------' as Owner of the subject
property
(2 :S\A."2 ~,~
l~tive to work authorized by this building permit application.
Date
I, vV\>Avt...'\_ ~~"L~0V" , 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 .
M~
3-1.:)-@
Sig Date
SECTION 8 -CONSTRUCTION SERVICES I
8.1 Licensed Construction Su~ervisor: Not Applicable D
Name of License Holder : M'IA-4_\l_ "S\A.V'L\4~, ~ (5-oS3 t./ '3 ..;
License Number
~Y<o..D :So.Al...~~· \}l\,p. 01.t>-:J'? y-~8-;> \
Expiration Date Add"'" 7:ZH 4,3-5/q ~':[_(,,
' Signature Telephone
9 . R~istered Home lm~rovement Contractor: Not Applicable D
:::$A-a \A--'\=\ v'\ ~ ~ .;>~ \ c9-ev-t..."' l~'fS89
Com~an)l Name Registration Number
~t j-llJ-:)D
-Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) . I
Workers Compensation Insurance affidavit must be completed and submitted with this applicatiqn. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes ....... Z No ...... D
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City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street• Municipal Building
Northampton, MA 01060
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 famil y 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: a 'tVA~-.e, \ Est. Cost:_g~b~1_0_0_0_-__
Address of Work: I \.f ~Y, '3-e:t yz ~ La .... ..,
Date of Permit Application: __ 3~-~'J~--';)~D~~-D ________________ _
I 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 HA VE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY F UND
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 appl y for a building permit as the agent of the owner:
3-\;;)-db~ D rY]lA!Zk l?(~,-4
Date Contractor Name HIC Registration No .
OR:
Notwithstanding the above notice, I hereby appl y for a building permit as the owner of the above property:
Date Owner Name and Signature
·-
"'I
.,
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building
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 house nu er and street name)
Is to be disposed of at:
of facility)
Or will be disposed of in a dumpster onsite rented or leased from :
(Company Name and Address)
urtl!lJA
Signature of Permit Applicant 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 .
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Natne (Business/Organization/Individual): __ :5_\A>rl._~\Ai~'.r'~-Y....~~~~~'->='~\~c;.9:,~_7~---------------
Address: S'5" e\)°)s:e\ lu\ \\-e 1€c.0
City/State/Zip: ~~~\AA nl-.. VV\ "4-6 \~ 1" ~ Phone #:
\
Are you an employer? Check the appropriate box:
--1.~ am a employer wit h 3 employees (full and/or part-time).*
2.0 I am a sole proprietor or partnership and have no employees working for me in
any capacity . [No workers ' comp. insurance required.] 3.o I am a homeowner doing all work myself. [No workers' comp. insurance required.) t 4.o 1 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
proprietors with no employees.
S.O I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers ' comp. insurance.t
6. D We are a corporation and its officers have exercised their right of exemption per MG L c.
152 , § I (4), and we have no employees. [No workers ' comp. insurance required.]
Type of project (required):
7. D New construttion
8. Ba'Remodeling
9. tJoemolition
10 D Building addition
11.0 Electrical repairs or additions
12. D Plumbing repairs or additions
13.0Roofrepairs
14.00ther _______ _
* Any applicant that checks box # I 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.
t 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. pol icy 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: __ fr~T~_\N\_~----------------------------
Policy# or Self-ins. Lie.#: WCC -~-:':5blq6or::J, -aa \'{ 4-Expiration Date: ']-I -db
Job Site Address: \\.9 lfaV\..f City/State/Zip: \/\
1 {6 \/\ , W\~ 0 \Ou"?
Attach a copy of the workers' compensati 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 ofup 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.
erjury that the information provided above is true and correct.
Si Date:
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. Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other ____________ _
Contac( Person: ___________________ Phone#: _______________ _
,.