185 CRESCENT ST Department use only
City of Northampton Status of Permit:
�.', Building Npartmont Curb Cut/Driveway Permit_
_
212 Moon Stroot Sewer/Septic Availability
Room 100 Water/Well Availability_ _
Northampton, MA-0-1 Two Sets of Structural Plans
�,�• . phos@ 413= 87=1240 Pax 4 , -4 i Plot/Site Plans_-_
Other Specify___
APPLICATION TO CONSTRUCT,ALTS ,RL AI NOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
-- 2020
SECTION 1 -;ITB INFORMATION
IA Preeerty Address: ;BQ�tio
NnRT!{q�j�,�� �r�SPECt70NS n to t@ gompleted by office
--�.; o r 060
Map yC' dot / / _ Unit
0 Zone Overlay District
Elm St.District CB District
IiBCTION 3°PROPBRTY OWNERINIPIAUTHORIZED A09NT
2.1 Own
w-5LL fA 18s G�� AmJL��
Nomas(10ftCuffont Moiling Addrsss-
IL Fd&' Qr�� T@loph®nay 13- 5$�- `I3/.S
di nota�ro
arind A011,
�. 5� �v �� S�• �i..lae,(.1� .lMtk� (1l�
Nomas(ft Cuffont Moiling Addrm°
S:44A Y1 -1 los
l lgRr I Tdo hon@
SECTION 3.INXIMATND CONSTRUCTION COSTS
7T-
lt@m Botim@t@d Cost(Dollars)to bay Official U§@ Only
m I d by p@rrnft applicant
I. Building (a4)Building P®rmit Foo
21 Elw1dool (b)Estimated Total Coat of
Construction from 6
3. Plumbing Building Pormit Foo
4, Moohoniaol(HVAC)
g. Fir@ Protwtion _
gt T@t@l=(1 + z+ 3*4+ 5) Chock Natmb@r
This n For Offlolal Use nl
BuildingP@rmit Nombor:_ Dot@
Ioaaood --
Bignoturw
Building commissioner/Inspector of Buildings Date
/ a S�'s @ r e-rY7 ra nL-�-
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4, ZONING All Information Must Be Completed. Permit can Be®@ni@d Pue To Incompl@t@ Information
ExiRting Proposed @iced by Zoning
`Phi§oplun,n to hg fill@d in by
nnilding UcpaF(�gnt
Lot Kiz@
Frontage
�t;tba�l�s nt
R: - L: - R:- --
l�
Building H ght —
Bldg,Squm Footage
Op@n Sp#@@ Fes@
(W wn mints§bldg A pawd
#of 2arl m Spaces
Fill!
A: Was a 6p@ciol p@rmit/Variano@/Finding ever been issued for/on the site?
NO ® DONT KNOW YES O
IF YIS, dol@ issu@d
IF YES., Was th@ permit recorded at th@ K@gistry of Doods?
NO ® DON'T KNOW ® YES O
IF Yli; enter Book Page and/or Document#
B. Does the sit@ contain a brook, body of water or wetlands? NO DON'T KNOW ® YES
IF YES, has a permit boon or n@@d to be obtained from the Cons@rvation Commission?
Needs to be obtained ® Obtained 0 , pate Issued'
Cr Do any signs exist on the property? YES NO
IF YES, describ@ size, type and location:
D: Are th@r@ any Proposed changes to or additions of signs intended for th@ prop@rty ? YES ® NO
IF YES, dwribe siz@, type and location:
1: WIII th@ construction activity disturb(olpHng,grading,2povotion,or filling)ov@r 9 acro or is it part of a common plan
that will disturb ovar f arra? YM NO
IF YES, then a Northampton Storm Water Manog@m@nt P@Fruit from tho DPW is required:
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ® Addition ® Replacement Windows I AlteraSon(s) ® Roofing
Or Doors E__1
Accessary Bldg. Demolition ® New Signs [o] Decks [C] — Siding[01 Other I"
Brief WorkDesaFlptlon of Proposed Ute\ C iyOVY J-10 13 IV'-eA, �i CpCA U
Alteration of existing bedroom Yee No Adding new bedroom Yes '� No
AOa@had Narrative Henoveting unfinished basement _ _Yee ✓No
Plans Attached Roll -Sheet
ga. If New house and or addition to existing housing, complete the following:
a. Om of building °One Family Two f=amily— Other—_ _ _
b. Number of Fooms in each family Unit- Number of Bathrooms
c: Is there a garage adached?
d- Proposed Square footage of new construction. Dimensions
e. Number of st@ries?
f. Method of heating? Fireplaces or Woodstoves Numb@F of each
g. Energy Conservation Compliance- Masscheek Energy Compliance form attached?_
h. Type of aon§tr C i@n
i. Is constru@tion within 900 ft,of wetlands? Yes No, Is construction within 100 yr, floodplain Yes No
i- Depth of basement or cellar floor below finished grade
k. WIII building conform to the Building and Zoning regulations? Yes No
i- Sept[o Tank City New Private well CItY Water SuPPIY
SECTION 7e-OWNER AUTHORIZATION-TO 59 COMPLETED WHEN
OWNKRlfl AGENT OR CONTRACTOR APPLILi FOR BUILDING PERMIT
I, W ,as Owner of the subject
property
hereby authorize � E
to art on my behalf In a matt WON wthorizod by this building permit a plication,
IL
G�
Signature o Owner Det#
as Owner/Authorized
Agent hereby declare that the statements and information @n a Dreg®ng application are true and accurate,to the best of my knowledge
and b@lief.
Signed and o pains and penaltfa Perjury,
q
Print N @
Signature of Owner/Ag Date
INCTION 1=CONSTRUCTION iNRVICEIIi
8.1 Licensed Construction Su ervisop Not Applipable ❑
Name of license Holder: (�- � ` CS"- Q I'j aS0/
Li@@n§@ Number
Signature Toi@phon@
__, Not Applimbl@
S G6��y�
N@gistr@tloR Numb@r
Addr@gf Expiration Data
T@I@ph®n@�f 13 3?I-q loS
GEECTION 10-WORK1I1111i'COMPLNiATION INAURANCE AFFIDAVIT(M.O.L.o.152,1250110
Worts@rs Comp@n§ation Insurance affidavit must be completed and submitt@d With this Applio8tion- p@ilUr@ to provid@ this affidavit will result
in th@ d@nl@I of th@ Is§Dance of the Wilding wrnit-
SI n@d AAid@Vit Att@oh@d Yes...---. N®......
The c'®mm mWea uh of Massachusetts
Dopurtmwnt of IndustrialAccidents
tints
a I Congress street,suito 100
Boston,MA 02114-2017
www,mass.gov/dla
Work@ml Compensation Insurance Affidavit: ltuild@r@/Contradon/Eiertririons/Piumb@m,
TO BE FILED WITH THE PERMiTTING AVTHORTTY,
Information
Nnsin�44,/A��pi �tiAn/In�iividi)� -
z�L Phone
Are yon on#mpinrert Gheek the#ppropriolt bam Typ@ of prnj@ct(r@quir@d).
17®14m it employeF with___ -employ@@§(full Nwor PRWfime),• 7. ❑New construction
1al#m 4§ml@ pFmpri@toF or pirtn@rship and hav@ no @mploY@@4 working fmr tri in g, ltemt�d@lin�
any RPagity,lido workers'comp.imumn@@ rquired.]
3.[J 1#m 4 bum@own@r doing#Ii work mys@if.[No work@r§'@omp,in§w#n@@ r@quir@d.]r 10
Aion
d�® trt@
1 am#hoown@r and will b@ hiring FPwwtafs to @mndu@t 411 work on my property, I will ®®l uildin uildln�&dditi®n
@04t"th#t 411 @mnImlors @ith@r h#v@ wmrk@Fs'@ornp@nsation insnF#n@@ or#F@ solo 11,®l;l@ctrical repairs or additions
pmPO tors with no employ@@§, 12,®Plumbing r@pair4 or additions
3.0 I#m#wn#r#i @onomfor god I h#va hirod the 40-vontr4ctors I istod on th@#tt#ohod&K 13,[] f
These§ub @ontF#@tmrs h#ve employ@@§#nd h#v@ workers'comp ininnn@e.tpg
irs
b-®W@#Fe#@orpor#tion and its officers hive @4@r@is@d their right of owmption p@r MUL @. 14,®mer
132,§I(4),#ad we h#v@ no employees,[No wafk@rs'@mt",in4w#nee Feguir@d:]
*Any#ppli@#nt th#t Eh@@ks box#l must also fill out the§@@tion below showing theiF woFk@rs'compcn5atiop pmli@Y information-
#Hotnemwn@rs who submit this affidavit indi@#ting th@Y#r@ doing all work 4nd th@n him outsid@ contractors most submit#naw Willovit indi@#ting§whr
Lantra@tor§th#t @b@@k this box must attach@d 4n additimn#I§h@@1 showing th@ n4m@ ofth@ 4nb @matm@tor4#nd stat@ wh@*vf of not tho4@ @ntiti@4 h#v@
@mploY@@s, If the 4ub=@ontmoors have employees,th@Y must provid@ th@ir workers'comp.Poli@Y numb@r.
/am an eiatpioyer that is providing workers'Compensation Insplronce for RV employees, glow is the Policy and jobs#e
information,
inguranc@ Company Ntnn@° —
Policy#or kelp fns.bis.. Expiration Aat@;
Job Site Addr@44: _city/Stat@/zip:
Attach a copy of the w®rk@m'compensation policy declaration pag@(showing the policy number and @xpiration date).
Fallt.•r@ to 4@@ur@ cov@rq@ 44 r@quWd und@r MUL c, 152, §25A is tt criminal violation punishabl@ by#fine ftp to$1,500,00
and/or An@=y@w lmpri4onm@nt,04 well a4 civil p@nalt1e4 in th@ form of a STOP WORK ORDER trod#fin@ of ftp to$250,00 it
day gitin4t th@ viol#t®r.A copy of thio 4tatem@nt may b@ forwit<rd@d to the Me of Investigations of the AIA for insurane@
@oV@r@A@ Verifttlon,
o da hereby Nn r the p pl plalties of P@r Jury thal the Information provider/above is true and correct.
5 L2o
Phone t L113-361)_91a<
Oftieial Nst on&, Do plot wr#o in this area,to be complexed by cl(y or town officlat
City or` ownl _ P@rmit/bic@ns@
Issuing Authority(circle one):
1, Board of Health 3, Building Department 3,City/` own Cl@rk 4.Electrical insp@ctor &Plumbing Inspector
b,Ath@r
Contact Pers®nl Phone#:
City of Northampton
Massachusetts
Ai
'1
DEPAIRDNW OF BUZZWX@ Xrafs07j0K# i
7 r 212 main @t€@@t •a j@i-P&I @".I"
N@F"WWtqft' NA 01060
Debris Disposal Affidavit
In accordance of the provisions of MOL c 40, 864, 1 acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit @ball be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, 6 15OA.
The debris from construction work being performed at,
14o!5- CRe.S96x .4.
(pl@es@ print house number and street nam@)
Is to be disposed of at
(Pl@os@ print name end location of aci I
Or will be disposed of in a dumpster onsite rented or leased from:
I,"S 20 O 4 0 C � �-e der '1Rtg'+ "J-30-s4qti
(Company Name and Address) _
ignature of P6r 10 or @wrier 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.
City of Northampton
Massachusetts
PEPARNT AjF 0(1�j4P.TNG INSPEC'TI@N8
NA 01060
AFFIDAVIT
Hom@ Improv@m@nt Contractor Low
Snppl@m@nt to Permit Application
`Ph@ Offlc@ of Consum@r Affairs and Business regulation("OCAHR")rcgulatcs the registration of contractors and
subcontractors performing improvements or renovations on d@ta@h@d on@ to four family Som@e:prior to
performing work on such homes,a contractor must N r@gistor@d as a Home Improvement Contra@tor("MCI')
M,G.L,Chapter 142A rmuir@s that the"moonstrmcticn, alteration, renovation, repair, modomir0on, conversion,
improv@m@nt, removal, demolition, or construction of an addition to any pro-existing own@"- ooYpi@d building containing
at 1@@8t cn@ but not mora than fcuF dwelling unit@....cF to structures which are adjacent to error residence or building"lac
don@ by contra@tors:
atst 4he homeowner has contracted with a corporation or LLC,that entry must he rswi'stsrett
`l?yp@ of Work= Est,Cost;
Address of Work.,
Dat@ of Permit Appllcatlon;
I h@r-@by c@rtify that:
r@glstratlon is not rewired for the following reason(s):
Work @xclud@d by law(@€plain);
Job under S l,®®®,®®
_owner obtaining own permit(@xplaln);
Building not own@r=oc@upl@d
Ath@r(sp@@lfy),,
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORD ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR OIIARANTV FUND
UNDER M,O,L,Ohapt@r 143A.Such OWNERS ALSO ASSUME THE RESPONSIBILTTES FOR ALL WORD
PERFORMED UNDER THE BUILDING PERMIT,SEE NEXT FADE FOR MORE INFORMATION,
Signed under th@ penalti@s of p@durys
I h@r@by apply for it building permit m the agent of the owner:
Ditto Contractor Name IIIC reglstratlon No,
OR:
Notwithstanding the above notic@,I hereby apply for it building permit as the owner of the abov@ property;
Date Owner Nara@ and Signature
NOR Satin IQI�HU`5,IHFAN19
0071,
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