949 florence road poolCity of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
Department use only
Status of Permit:
Curb Cut/Driveway Permit _______ _
Sewer/Septic Availability ________ _
Water/Well A vailabilify _________ _
Two Sets of St ructura l Plans. _______ _
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 Pro11ectir: Address: This section to be completed by office
{{49 F /u (<.eNeG .f<Dith Map Lot Unit
No/Zffffl!Y7(Jnv, tv!A ()/Offt Zone Overlay District
Elm St District CB District
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SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
11/ou /IJJrJJf /rJ.J I j)llf} -JiJ1/I Mi)/,,,t<fvµS qv1 v/oll.t!NW Id.
Name(P~ Current Mailing Address: ~ ()I at:.o1,
~l ~ -q~ ~ -S:r> 2 ~/ ~ -----... Telephone
Signatvfe,..-/ ...... ....___
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 -ESTIMATED CON§TRUCTION CO§TS I
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 1500 (a) Building Permit Fee
2 . Electrical ! 100 (b) Estimated Total Cost of
Construction from (61
3. Plumbing Building Pennit Fee
4. Mechanical (HVAC)
5. Fire Protection J
6. T otal= (1 + 2 + 3 + 4 + 5) ./ f,iOQ Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
@ V ,q I-too . (! 0 ff/\.
I
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Reviewed/Approved 4/2/20 Louis Hasbrouck
Note; Pool decks must be approved before construction, safety barriers
must be in place and inspected before pool is filled with water.
~ G All lnfonnation Must Be Completed. Pennit Can Be Denied Due To Incomplete lnfonnation
~ Existing Proposed Required by Zoning
This column to be fill ed in by
Building Department
Lot Size i
Frontage I ·--·---! I
Setbacks Front CJ r--, CJ j L.._.
Side L:c=:R:CJ L:c:=-' R:L ____ ! L ] L I
Rear [:=J r-·1 L_J '0
~ Building Height CJ CJ CJ
~
Bldg. Square Footage CJ CJ % CJ CJ CJ
Open Space Footage
CJ CJ
%
CJ CJ CJ (Lot area minus bldg & paved
parking) ~
# of Parking Spaces CJ c_J CJ 0\
Fill: [ r------. · 1 .
r
/ volume & Location l I
A. Has a~-P-< cial Permit/Variance/Finding ever been issued for/on the site?
NO F DONT KNOW O YES O
IF YES, date issued:J I
IF YE\o Wl permit r;;~~::~=e cttry of Deed~?ES 0
IF YES: enter Book I ! Pagej and/or Document#'~----~
B. Does the site contain a brook, body of water or wetlands? NO Fi-. DONT KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued: I ~-----
C. Do any signs exist on the property? YES 0 NO ¢.
IF YES, describe size, t ype and location: .._ ___________________ __,
D. Are there any proposed changes to or additions of signs intended for the property? YES 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 Q NO 9-
IF YES, then a Northampton Stonm Water Management Penm it from the DPW is required.
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SECTION 5-DESCRIPTION OF PROPOSED WORK (check all applicable)
New Ho use D
Accessory Bldg. ~
Addition
Demolition
D
D
Replacement Windows Alteration(s)
0rDoors D
New Signs [t:J] Decks (0
::~~escription of Proposed ABl>I/G GJZooll)Q
D Roofing D
Siding [t:J) Other [CJ)
Alteration of existing bedroom ___ Yes ___ No
Attached Narrative
Adding new bedroom ___ Yes ___ No
Plans Attached Roll -Sheet
Renovating unfinished basement ___ Yes ___ No
a. Use of building : One Family ___ _ Two Family ____ Other ____ _
b. Number of rooms in each fam ily 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 Compl iance. _________ Masscheck Energy Compliance form attached? ______ _
h. Type of construction ______ _
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. SepticTank __ CitySewer __ _ 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.
Date
I, lfm /11.r,Ll/'bfllf ,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.
Date
SECTION 8 -CONSTRUCTION SERVICES I
8.1 Licen sed Construction Su11ervisor : Not Applicable D
Name of Lis.gnse Holder :
License Number
Address Expiration Date
Signature Telephone
9. Regi!ltered Hom 2 lm11r2vem2at C!;!ntract2r: = .. Not Applicable D
C om11a nl£ Name Registration Number
Address Expi ration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 1 52, § 25C(6)) I
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....... D No ...... D
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Stroot• 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 family homes. Prior to
performing work on such homes, a contractor must be registered as a Home Improvement Contractor ("H1C").
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.
TypeofWork: &ovtf (pli>U,1/J) Pool Est.Cost:$-'6-..::C:O;...c._ __ _
Address of Work: ql{C, 'F10 r'Z~ef ~ D-h/.,HZ tJt!rnz a'vrJ llAIJ 0/0(.p;).
~l
Date of Permit Application: _ __,.3'-+-/cJ.."--S"--l-/_,,2_"--'--'o'-J..."--~O ______________ _
I I
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 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 above n otice, I h ereby apply for a building permit as the o
-r" --r----::Z:~
Dat
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street• Municipal Building
Northampton , MA 01060
Massachusetts Residential Building Code
Section 110.R5.l.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.RS. l.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 11 O.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 unde r 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 p erform work for you
under this permit.
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Hunicipa1 Building
Northampton , Ml\. 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:
(~~:prin'::a(~~~nd /}:!; na &,t>flf'J/i!nJfh->JJ I /IAA {)/ b (p J_
Is to be disposed of at:
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and ~ess)
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.
o,o~v
~ The Commonwealth of Massachusetts
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia •
D,parlment of Indu,t,;a/Accukn•
Workers' Compensation Insura nce Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/0rganization/Individual): __ JL.._.-'-!Yl'--'--"-/Jll-"o"'-"-l-'-l...,fo_""'/LJ~$.._ _____________ _
A ddress: C/'iC; Av e.t-:JIJC 0 £Ml)
.-Ci...:...ty_/Sta_t_e/Z-----'ip'......:: =Af)===fl=1lf.=7=q}=Y/t:::::::::=.tJi'/7)=,J-=t:.' f!l=='l}=Q=YO=W.:::.....:..:.Ph....:....on....:....e....:....#:==J/.==/3=/,;:::::::::qd=3=~=g.=~='(J =J =J ===-+4.~ , i)I,'~
Type of project (required),:\"t{ (f'' Are you an em ployor? Check the appropriat e box:
1.0 I am a employer with ___ employees (ful l 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.] @1 am a homeowner doing all work myself, (No workers' comp. insurance r,,quired.J t
4,0 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 arc sole
proprietors with no employees,
S,0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These su~contractors have employees and have workers· comp. inswancc.i 6.o We are a corporation and its officers have exercised their right of exemption per MGL c.
1S2, §1(4), and we have no employees. [No workers' comp. insurance required.(
1. SNew construction tvveo e,
8. 0 Remodeling r .
9. D Demo lition
10 D Building addition
11.0 Electrical repairs or additions
12.O Plumbing repairs or additions
13.ORoofrepairs
14.O 0ther _______ _
• Any apphcant that checks box# I must also fill out the secllon below showing their workers' compensation pohcy 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# o r Self-ins. Lie.#: __________________ Expiration Date: ________ _
Job Site Address:. _____________________ City/State/Zip: ________ _
Attach a copy of the workers' compensation policy d eclaration 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 fonn of a STOP WORK ORDER and a fine of up to $250.00 a
day against t~e vi~lator. A copy of this sta~jJJAllay be forwarded to the Office of Investigations of the DIA fo r insurance
coverage verification. ~
and penalties of perjury that th e information provided above is true and correct.
Date: 3, :;2 5 ~v :2-O
Phone#:
Offidal use only. Do not write in this area, to be completed by dty or town official
C ity or Town:______________ Permit/License# ______________ _
Issuing Authority ( circle one):
I. Boa rd of Health 2. Building Department 3. City/Town C lerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other ____________ _
Contact Person: ___________________ Phone #: ______________ _