25-026 (7) _ -..i epa men use"on
City of Northamp)on Status of Permit:
Building Department MAY - JgUM Cut.Driveway Permit
212 Main Street Sewer/Soptic Availability
Room 100 WaterA1011 Availability
EPT.OF 6UILDING 1 ''Js
Northampton, MA 0106$ NORTHAA4PTnN O4,,0s of Structural Plans
phone 413-587-1240 Fax 413-5877-11227 PlotlSite Flans
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
,"z 4( cd1-11lt �.� Map ty, Lot Unit
�"J Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: / Q
Name(Print) Current Mailing Address:
3Zo -71��z
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS -- \
i
Item Estimated Cost(Dollars)to be Official Us my
completed by permit applicant
1. Building -301 4 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Z/ J iJ d Construction from 6 - "
3. Plumbing 2 J U O Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection , o D
6. Total =(1 +2+3 +4 +5) -7 Check Number
/t y This Section For Official Use Only
Building Permit Number: 6P_C� Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings 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 Size6
Frontage
Setbacks Frontr�f F771/ o;
Side L:� R:� L:U R: 0
Rear t ro l E:�:f 0
Building Height Fzl FE-7
Bldg. Square Footage M3% = % asp
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces 1 `I
Fill:
volume&Location)A. Has a Special Permit/Variance/Fin in ver been issued for/on the site?
NO O DON'T KNOW YES O
IF YES, date issued:F-
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW O YES O
IF YES: enter Book I I Page[ and/or Document#
B. Does the site contain a brook, body of water or wetlands? NOR—
O Rf DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YESO NO
'J�r
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, gradin exca ation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO A
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 Alterations) ❑ Roofing ❑
Or Doors I]
Accessory Bldg. ❑ Demolition ❑ New Signs [EI] Decks [p Siding [p] Other[O]
Brief Descripti n of Proposed 7 �_
Work: 9^/-A< C 4J �?` L �ted/ v r +A
Alteration of existing bedroom Yes No Adding new bedroomes No
Attached Narrative Renovating unfinished baser retlt Y 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
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
9. Registered Home Improvement 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....... No...... ❑
City of Northampton
r Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building v� ►`
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("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: Est. Cost:
Address of Work: �� /�c , �* ��C /J) /(-.,-
Date of Permit Application:
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): 0zj/I e/ E--
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 notice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
r ' Massachusetts
. _ DEPARTMENT OF BUILDING INSPECTIONS S1
1 212 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 number and street name)
Is to be disposed of at:
(Please print hame and location of fa ility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
(s Cv
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.
DAVID MELLO
BOOK 13175, PAGE 132 DAVID W. MELANIE A. FOURNIER
PLAN BOOK 31, PAGE 61A BOOK 6741, PAGE 318
PUN BOOK 178, PAGE 235
PARCELS 2 3
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DAVID MELLO 1 oPG AGE
BOOK 13175, PAGE 128 r
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SEE: PLAN BOOK 31. PAGE 61A ,i PINKY HOTA
SUBJECT TO AND TOGETHER WITH s,3 VINAYAK RAMANAN
THE RIGHT TO USE A CESSPOOL % >< �yv. Z BOOK 11756, PAGE 206
a1 PLAN BOOK 176, PAGE 235
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RIVERBANK ROAD
"BUILDING PERMIT"
PLAN OF LAND IN
LOCUS NORTHAMPTON MASSACHUSETTS
RICHARD H. WATLING
BOOK 9M, PAGE 19 RICHARD WATLING
PLAN BOOK 176, PAGE 235
LEGEND PARCEL 1 — SCALE: 1'-20' MARCH 22, 2019
HAROLD L EATON AND ASSOCIATM INC.
o FOUND IRON PIN �� REGISTERED PROFESSIONAL LAND SURVEYORS
• IRON PIN TO BE SET
E. 23;5 RUSSELL STREET — HADLEY — MASSACHUSETTS
x35032 413-584-7599 413-5&S-5978 fax
0 FOUND CONCRETE BOUND email — hlootonOool.com �
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