22B-008 (12) 130 SPRING ST BP-2009-0753
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:22B-008 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Categ_oa: BUILDING PERMIT
Permit# BP-2009-0753
Project# JS-2009-001121
Est.Cost: $5200.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: THOMAS DOLAN 039281
Lot Size(sq. ft.): 65775.60 Owner: PEASE THOMAS R&PEGGY-ELLEN
Zoning: GI(100)//wsP Applicant: THOMAS DOLAN
AT. 130 SPRING ST
Applicant Address: Phone: Insurance:
P O BOX 297 (413) 585-0612 () Workers
Compensation
CHESTERFIELDMA01012 ISSUED ON.•4/2/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR 12 X 14 WATER DAMAGED ROOM
(WINDOWS,DRYWALL,INSULATION)
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke. Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Sisnature:
FeeType: Date Paid: Amount:
Building 4/2/2009 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
,a
a `
File#BP-2009-0753
APPLICANT/CONTACT PERSON THOMAS DOLAN
ADDRESS/PHONE P O BOX 297 CHESTERFIELD (413)585-0612 Q
PROPERTY LOCATION 130 SPRING ST
MAP 22B PARCEL 008 001 ZONE GI(100)//WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid Vv
Typeof Construction: REPAIR 12 X 14 WATER DAMAGED ROOM(WINDOWS,DRYWALL,INSULATION)
New Construction
Non Structural interior renovations
Addition to Existing
_ Accessory Structure
Building Plans Included:
Owner/Statement or License 039281
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9WAATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Del
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
, 4
Department use only
- City of Northampton Status of Permit:
Building Department Curb Cut/DriVeway F'emlit
- 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
MAR 1 8 2009 Northampton, MA 01060 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
1.1 Property Address:
This section to be completed by office
�3b S'Pra/rtc.� �j 7�- Map Lot Unit
i Zone Overlay District
a/o6z
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
7 1 Owner of Ru_rn_rt+ leq-ser.t�.. e ,,,7
Name(Print) Current Mailing A(fdress:
Telephone
ignatureOa if
2.2 Authorized Agent:
041 a.64A/ l�p.��.� 7 GGI,PSfc°� fele/ 06, 0/01z
NamePrint) Current Mailing Address:
oF�h y/S' 5'Ss 061 z /eel 497-VdV
Signa ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a),Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 3�20D. °t7 Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
- --
Bwldirig Commissioner/Inspector"of"Buildings —" Date
� . .
~* .
Section 4. ZONING All.Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existina Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has aSpecial Permit/Variance/Finding ever been issued for/on thesite?
�� ��
NO \`�� �/ \_�� DON7KNOYES \��
/---�----------<
IF YES, date issued:' `
IF YES: Was the permit recorded at the Registry of Deeds?
NO �-��~/ DO�~\ N7KNOYY �=� .E^ _
IF YES: enter Book Page and/or Ducument#
B. Does the site contain abrook, body nfwater orwetlands? NO 0 DON7KNOYY 0 YES 0
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobeobtaned Obtained �~� Date' v~�-�/ Ob� ' v�� ' '
v�� �-1
C. Doany�gnsexist onthe prope�y? YES t~�/ NO v_�
IF YES, describe size, type and location: /
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, gradingexcavation, nrfilling)over 1acre orinitpart ofocommon plan
that will disturb � )uUzover1 aure, y�u NO
� )
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[01 Other[p]
Brief Description of Proposed .1/,fv�uN�d lob /oZ. ,P�ri tN .9iir/fiw�
Work: I51^/6da i i.✓
C�1AfvAa fvw
Alteration of existing bed oom Yes_�No Adding new bedroom Yes --' No
Attached Narrative Renovating unfinished basement 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 A
to act on my ha4aatters relative to work authorized by this building permit application.
t
Signature of O Date — Jg.of
I, / O Ao-_ ,[ )p��wr� 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
Signatur f Owner/Agent c Date
A ' '
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: /�) f Not App►plliicable �❑j Q
Name of License Holder: �iM ,�/a��/V (�7
License Number
o. mor C�� Cl��sfc�,� 2611 At. 0/02 .0?- d'- �Do
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
�_DwAtu V1011. /e!4'5 00
Company Name Registration Number
?_..I� , XOX 60i G`lc°S9- 2s- �oio
Address Expiration Date
Telephone SPs=66/L-
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...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor.CINIR 780. Sixth Edition Section 108.3.5.1.
Definition of 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.
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 under 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 perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
The Commonwealth oflYlussachusetts
X
Department of Industrial Accidents
A.. E Office oflnvestigations
600 Washington Street
— ^ Boston,.M_4 01111
www.massgov/diu
Workers'Compensation Insurance Afnda-rit: Builders/Contractors/Electricians/Piumbers
ADPHCant Information / Please Print Legibly
Name(Business/Or�-,,mizadon/Individual):
Address: 7
City/Staxe/Zip: CSI��°� fin/�l�Y� Di9.1z Phone.T: =06/2
Are you an employer?Check the appropriate box:
1.Rri am a employer with / 4• ElI am a general contractor and I Type of project(required):
employees(full and(or part-time).* have hired the sub-contractors 6. ❑New construction
' 2.Q I am a sole proprietor or partner- wed on dee attached sheet. 7. ,E]Remodeling
ship and have no e=plo'ees 'These sub-contractors have g- ❑Demolition
working for me in any capacity. employees and have wozk=s'
[No woes'comb: suunce camp.insurance.+ 9. ❑Bunldmg addition
required.] 5. i ri e are a corporation and its 10.0 Electrical repairs or add'ition's
3.❑ I am a homeowner doing all work officers have exercised their 11.El Plumbing repairs or additions
myself [No workers,comp. right of exemption per 1 fGL 12 0 Roof repairs
an=nce required.]t c. 152,§1(4),and we have no
emPIoyees.[No workers' 13.0 Other
comp.insurance required-]
` Y aPP I� caer ooz mut aso an out me secaon oeraw snowing MW woric=I cotnpe cation.policy Infornittion.
t Homeowners who submt this affidavit main they are doing all worst and then fine outside connactots mist subffit a new affidavit indicating such.
�4Contrwtors that check this box a st attached an additional sheet showing the name of the sub-contractors and state avuedser or not those entities have
eMTloyees. If the sub-contractors.have ecmpioyes,they nnist provide their workers'co policy number.
mP•P �7'
lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
tnformation. 1
Insurance Company Name:_ `.,/�p��./ U7 /0 4
Policy#or Self-ins.Lic. #-A& 2 -- 3/4r-36 Z I fV- 0/-7 Expiration Date:- 5-- 2,� - O t
Job Site Address: e(showiCity/Stata�Zip:.
Attach a copy of the workers'compensation policy declaration pagng the policy number and expiration date).
Failure to secure coverage.as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil nenalties in the form of a STOP WORK ORniLR and a Fr
of cup to$250.00 a day a'oamst the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investisations of the DIA for"_trance covera.se verification.
Ido hereby certify under the pains andp.9#des ofperjury that the information provided above is true and correct
v rcrai use only. Do not write to this area,to be completed by cuy or town olowaL
t6.
ity orown:_suung Authority(circle one):Board of Health 2.Building Department 3. City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector
Other
ntact Person: Phone T-
D EPtt?ZTMENT OF E UILI?D�G li�i SPECTIONS
INSPECTOR 212 Nfidn Street a Munidpal Buildin- ,
Nurt=pton,MA 01060
R^v E ON NER LXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to
act as ',is/her construction sup^_,P:sor. The state defines "Homeowner. as, "Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building4epartment for the City of Northampton wants any person(s)who seek to
use fhe home owner exemption, to act as their own construction supervisor,to be aware
that by doing so you become responsible for compliance with state building codes
and regulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before bacl jEL
sonotube holes (before uour) a rough buildine insuection°(before work is
_ cancea-led)...insulation insaection (if reu.uired-)arida.._fin.al_buildina.insnecti.o:n. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancv
unA-the wart; mn—be inspected-
If the
nsbected.Ifthe homeowner hires other trades to perform work(electrical, plumbing&'gas) the
homeowner will,be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections.Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above_
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me. y
Date
Address of work
location