129 Riverbank 20-5-6City of Northamp on
Building Departm nt
212 Main Stre t
Room 100
QEPT. OF BUIL DING J Northampton, MA 1 06u NORTHAMP10N.
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION I
This section to be completed by office
Map ~5 Lot ocW Unit,_ __ _
0 IDG, 0
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
£,~4~,J LJ~~\. ~5
Name(~:::::=§~;;;:===:=::----
Signature
2 .2 Authorized Agent:
Name (Print)
Signature
SECTION 3 -ESTIMATED CONSTRUCTION COSTS I
Item
1. Building
Estimated Cost (Dollars) to be
comoleted bv permit aool ican t
] ()
1
Doo
Zone ______ OVertay District _______ _
Elm St. District CB District
I
Current Mailing Address : •</'. S"/1 :J'<-o -7.cYz
Telephone
Current Mailing Address :
Telephone
---Official UswOrlly
/ -1.I -/?
(a) Building Permit Fee
2 . Electrical "?...1 v O 6
(b) Estimated Total Cost of '-.... ~ __ v
Construction from (6)
3 . Plumbing :z.,uoo Bulldlng Pennlt Fee
4. Mechanical (HVAC)
5. Fire Protection
6 . Total= (1 + 2 + 3 + 4 + 5) Check Number / '1 I
I This Section For Official Use Only
Date Building Permit Number:.___..cf..__---'a ___ o_---'/a....o.../ "'"'/ 3>"'-----Issued : _________________ _
Signature: ------------------
Building Commissioner/Inspector of Buildings
@
Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Mu st Be Completed. Pe rmit Can Be Denied Due To In complete Info rmation
Existing Proposed Required by Zoni ng
This co lumn to be fi ll ed in by
Building Department
Lot Size I ~ 106 11 < J O C) I I
l-S ' -/
Frontage I 11 /...5 11 I
Setbacks Front CW5r [2£]' c=J C)
Side L : l R :~ L:~R: c=J c=J ------
Rear [zfil CT] c=J
Building Height ~· CTI ' c=J
Bldg. Square Footage ~ c=J % ~ c=J CJ
Open Space Footage ~ c=J
% ~ CJ CJ (Lot area min us bldg & paved
parking)
# of Parking Spaces CZl-c?J c=J
Fill: I () II 0 II I (volume & Location)
A. Has a Special Permit/Variance/Fin~er been issued for/on the site?
NO O DON'T KNOW 8 YES 0
IF YES, date issued :! j
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES 0
IF YES: enter Book j j Page!~ ___ __. and/or Document# I._ _____ __.
B. Does the site contain a brook, body of water or wetlands? NO&-' DON'T KNOW Q YES Q
IF YES , has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued: .... I _____ __.
C. Do any signs exist on the property? YES Q NO &:
IF YES , describe size, type and location: I.__ ____________________ __.
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
IF YES, describe size , type and location:
E. Will the construction activity disturb (clearing , gradin~ation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO }O)
IF YES , then a Northampton Storm Water Management Permit from the DPW is required .
SECTION 5-DESCRIPTION OF PROPOSED WORK (check all appllcable)
New House D Addition Replacement Windows Alteration(s) 0
Or Doors D
Roofing D
Accessory Bldg . D Demolition D New Signs [DJ Decks ID Siding [DI Other [D]
Brie f Descrip!i9n of Proposed n
Work : C.:::,....p,. rA s e ~ /JZ I \-c;.'r (.) ,.,,JI
Alteration of existing bedroom ___ Yes '><-No
Attached Narrative ---tj-'.
Adding new bedroom ~es ___ No
Renovating unfin ished baseMt Yes .. < No
Plans Attached Roll -Sheet
. If New house and or addttlon to existing housing. complete the followlna :
a . Use of building : One Family ___ _ Two Fam ily ____ 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 . _________ Dimens io ns ---------------
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 ______ _
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 th is building permit appl ication .
Date
I , , as Owner/Authorized
Agent hereby declare that the statements and information on t he 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 D
Name of License Holder : ______________________ _
License Number
Address Expiration Date
Signature Telephone
• ... .i •..... 1 Jl .. , • ,•.11 I 1.. Not Applicable D
Company Name Registration Number
Address Exp iration Date
______________________ Telephone _______ _
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 162, § 26C(6)) I
Workers Compensation Insurance affidavit must be completed and submitted with this appl icat ion . Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes ....... ·Rf' No ...... D
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 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: I/the homeowner has contracted with a corporation or LLC, that entity must be registered.
Type of Work: __ A_JJ~_l _-1-_<_o_,....., __________ Est. Cost: __ '3 __ 7_/<_t:' __
Address of Work:_/_7___~ _ __.__/(-"--'c'-"---.j-<L"""---'s. ........ ~ -'=~--'--~___.{.._· ---'J'-----')J'---_:> .._r--"-J--~--~----L..M.,,f:-""'--==----
Date of Permit Application: S,-c.r, --'-<:::> Z.o
I hereby certify that:
Registration is not required for the following reason(s):
_ Work excluded by law (explain): ___________________ _
Job under $1 ,000 .00 j
_ Owner obtaining own permit (explain):_O=---u--'-/1---'----c:.---'/ ___ B_~_, _f_-_"__,_\ __ 4--'-""J,_J"""'--','-',f'-,-=~"-'/)"-'-
__ 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 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 :
5'-6 -'lo '"Le:, If«-~~ ~ N-1 r ~ y ~~=======----
Date Owner Name and Signature
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 number and street name)
Is to be disposed of at:
Or will be disposed of in a dumpster onsite rented or leased from :
(Company Name and Address)
SignatureofPerrnitAplicant 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 .
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f'OUND IR(lt PN
IRCIN PIN TO 8E: SET
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FOUND S'lONE IOUND
UNMARKD> PONT
RIVER9ANK
LOCUS
IIOWID H. •11.M laac .... P,.._tl
Pl.AN IICIC 178. PAGE 2315
PMCa 1
ROAD
"BUILDING PERMtr'
PUN OF I.MD M
NORTHAMP~ MASSACHUSETTS ...,.MED FOR
RICHARD WAlUNG
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