18C-031 (6) 16 COOKE AVE BP-2008-1094
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C-031 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-1094
Project# JS-2008-001618
Est. Cost: $3000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Roger Clark 021310
Lot Size(sq. ft.): 19340.64 Owner: BUSHEY TIIOMAS G
7nr no• St.' Applicant: Roger Ci^rrk
AT: 16 COOKE. AVE
Applicant Address: Phone: Insurance:
P O Box 34 (413) 586-1491 ()
LEEDSMA01053 ISSUED ON:6/12/2008 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR FOUNDATION
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.Y.W. Building Inspector
Underground: Service: Meter:
Footings: 147
Rough: Rough: House# Foundation:�/� � �S
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE TY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc Si nature:
FeeTvpe: ate Paid: Amount:
Building 6/12/2008 0:00:00 $50.005572
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
f
File#BP-2008-1094
APPLICANT/CONTACT PERSON Roger Clark
ADDRESS/PHONE P 0 Box 34 LEEDS (413)586-1491 ()
PROPERTY LOCATION 16 COOKE AVE
MAP 18C PARCEL 031 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 0e co'
Typeof Construction: REPAIR FOUNDATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 021310
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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 Delay
.7/
Signature of Building fficial Date p/. v
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.
• Department use only
City of Northampton Status of Permit:
r-� Building Department Curb Cut/Driveway Permit
r... 212 Main Street Sewer/Septic Availability
^l \ _- Room 100 Water/Well Availability
.J, F Northampton, MA 01060 Two Sets of Structural Plans
, '- 0 - ) one 413-587-1240 Fax 4137 587-1272 Plot/Site Plans
1: ,._1 \ Other Specify
�tiS
I CATIO�I.TaCON T,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
\ztr___
-
TION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
LL
•
0 C( Au-e Map _. Lot Unit
Zone Overlay District
Np:C1-ku04,E1-c AMA oi0 ( O
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
—TIvavv't G i 1- r? S 'PI_ 1 (<) 0066 !A`'-e
Name(Print) Current Mailing Address:
--rtle-m.4.41A A Is(ka05, . Telephone '•
Signature It i 71 - c gy- it a`F
2.2 Authorized Agent:
I`o e` C C /4c k B 0 x 3 if L EED s1 ,'i g 6/o 5-3
Name(Prin4j ,/ / Current Mailing Address:
�J'��. , C Y/3 - 576 — /99/
Signat rd e / Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit aoolicant
1. Building 3 DUO (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) ,. o oo Check Number 74P- 0.50 —
This Section For Official Use Only
Building Permit Number Iss
te Issued:
Signature:
Building Commissioner/Inspedt buildings Date
Section 4. ZONING ( All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Inforgmation
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage - _
Setbacks Front
Side L: '
Rear ----
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved �. .
narking)
#of Parking Spaces
Fill: _ ------
(volume&Location) ----
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES O
IF YES: enter Book Page and/or Document#T�
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 , 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? YES O NO
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
IF YES,theF a Northamptbn Stoml Water ant a eme it Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [El Siding[p] Other[
Brief Description of Proposed ? 1 t /`1 j
Work: Lip mot) JQ / CDhLf L b10Ci� `0vr &{IOn. f rCrkC_G to;Tk. rUr CJOA.Cre `.
Alteration of existing bedroom 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
•
, as Owner of the subject
property ff _ L
hereby authorize i--� er C I eker—
to act on behalf, in all matters elative to link authorized by this building permit application.
Signature of Owner Date 5 a_
I R� tr- —I&r , asC r/Authorized
Agent here y de are 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.
ny --'f,1.1 . — --
Pnnt Name
Signature of Agent Date
9 9
r
SECTION 8-CONSTRUCTION SERVICES ,
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: K O!{ f Char -/310
cJ License Number
6o4 3 `l L e cc�s ,A ,q o ios 14.3/ie
Address / a Expiration Date
Signature 1 c L//3 — ��(o"- /v 1
�9 Telephone
9.Registered Home Improvement Contractor. • Not Applicable 0
leoy..er C/ -k Grn Lenf. /0/87`t
Company Name Registration Number
v? 3 /t/. Map 1e 7- VaJjie9
Address- t,//!' Expiration Date
/0061C-e- / D�D 6 & Telephone Ll/3-Sre'/�j /
-
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 t! No 0
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.CMR 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
Office of Investigations
_ .`ro ... 600 l�ashington Street
Boston,MA 02111
www.rnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lesibl
Name (Business/Organization/Individual): _
A AA,-
c'auA.sc ens:
City/State/Zip: Phone #: •
Are you an employer? Check the appropriate box: Type of project(required):
1.0 I am a employeewith 4• 0 I am a general contractor and I employees (full and/or part-time).*
6. ❑New construction
have hired the sub-contractors
2.[Tam a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
13.2 Other ,trj
insurance required.) t c. 152, §1(4), and we have no .
employees. [No workers' � �o-� vne, '�
comp. insurance required.] .
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
l'Ho meowners 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-cormactors 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#or Self-ins.Lic. : .Expiration Date:
. Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page (showing 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 S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby-certifywader-rito-p rrs-rrmfpendrresTef-per at the information provided above is true and correct.
Si�Iature: � - Date: . . . , /aa/a•7
Phone#: y(3— ST&o- / get I - . ..
-= Q ficiaL rcre 0.rz1 D_a not writejnnlhi..ar-eu,_to be eomp1ad y city or town2fAcLaL 11
City or Town: Perrnit/License
Issuing Authority(circle one): i
i.Board of Health 2. Building Department 3. CityiTown Clerk 4.Electrical Inspector 5. Plumbing Inspector 11
I 6. Other
I'
il Contact Person: Phone =: I.
t: cf . ' ,ran:sac�asrN. i
49 C =.iM X2 ii c t c'._I—LNG `NNi s Ec ZOVS �, _c
.1 2 M 1 'n i ii i.rt
IN:rGCTOK i ::z..S[:_ • Q.::ic:^a a c_st
Northampton,141A Oi0c0 ---�
I
•
ROM. OWNER EXEM31 N ACKNOWLEDGEMENT
•
I The State of f;.ccar%buse'ts allows the homeowner the rig&Tmr'Pr 78OQs . 103.3.4 to i
act as i is her construction supc: isor. The smote dines"Homeowner"as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two family
d ve lin , atiached or detached t uc._res accessory to such use and/or farm structures. A
person who contra s more than one home in a t~wo-year period hail not be considered a
home owner."
•
The 4ep pert for the City ofNoxi'-npton v, 2s any pe:scn(s)who seek to
use the home owner exemption, to act as their own ccnsti i on sip e.^rsor, to be aware
that by doing so von become responsible for compliance with state building codes
and regulations.The inspection process eq7. s that the building department be plied
to inspect wort at various sta.Ees, which include foundation/footings (before bacld"lll).
sonotube holes (before Dour). a roush building insue ou(before work is •
co eale.-T.,T. kr,-o :.s ecti n-(if repaired)art a fail bm 7 a irtnec_tion.The
building deo nera-r --...res the inspections before the words concealed, failure to
sure these inspections can result in failure to obtain a certificate of occuuancv
u e-worlr.buss _.- . •
If the horreaw-ner hi- other trades to perform work(elect iici, plumbing&gas) the
homeowner will.be responsible to make sure that the trades hired se^.,,tre 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 p its and inspections as
re ured can DELAY the project until such tithe as the proper pits and inspections are
made
- --— tmderd.the above.
(Ilona:e owner/resideit's signature requesting ezenipdon).
I will caif to schedule all required building inspection_necessary for the building permit
issued to me.
,_
Date -
A rir!re. of work . -
-. . -_= ...
location -- -. ...