12C-070BP- 2011 -0608
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category
Permit # BP- 2011 -0608
Project # JS- 2011- 000972
Est. Cost:
Fee: $25.00
Const. Class:
Use Group:
Lot Size(sa. ft.): 11630.52
Zonin URA (100) / /RI /WSP
BUILDING PERMIT
PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
Homeowner as Contractor
Owner: VELETA DAVID
Applicant: VELETA DAVID
AT: 42 CAROLYN ST
Applicant Address: Phone: Insurance:
42 CAROLYN ST (413) 586 -1294 0
FLORFNCEMA01062 ISSUED ON :11412011 0:00:00
TO PERFORM THE FOLLOWING WORK.- INSTALL WOODSTOVE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Rough: Rough: House #
Driveway Final:
Final: Final:
Gas: Fire Department
Rough: Oil:
Final: Smoke:
Footings:
Foundation:
Rough Frame:
Fireplace /Chimney:
Insulation:
Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 1/4/20110:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
'
Department use only
City of Northampton
Status of Permit:
Building Department
Curb Cut/Driveway Permit
212 Main Street
Sewer /Septic Availability
1 6 01 Room 100
Water/Well Availability,
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
This section to be completed by office
1.1 Property Address
+d, C J<)
Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
David K. Veleta
42 Carolyn Street
Nam ri ) _
Current Mailing Address: 413- 586 -1294 (H), 587 - 10 9 6 (W)
Telephone
Signature
2.2 Authorized Anent:
NA
NA
Name (Print)
Current Mailing Address:
NA
Signature
Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollars) to be
Official Use Only
completed by ermit applicant
1. Building
0
(a) Building Permit Fee
2. Electrical
(b) Estimated Total Cost of
0
Construction from 6
3. Plumbing
0
Building Permit Fee
wkit, MRAu cV\E'( -'K
4. Mechanical (HVAC)
-
5. Fire Protection
6. Total = 0 +2+3+4+5)
0
1 Check Number Z5 ' , (70
This Section For Official Use Onl
Date
Building Permit Number:
Issued:
Signature:
Building Commissioner /[nspector of Buildings
Date
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 Size
NA
NA
NA
Frontage
NA
NA
NA
Setbacks Front
Side
Rear
L: R:
L: R:
Building Height
Bldg. Square Footage
%
Open Space Footage
(Lot area minus bldg & paved
p arkin g)
%
# of Parking Spaces
Fill:
(volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO ® DON'T KNOW O YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW ® YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW ® YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ® , Date Issued:
C. Do any signs exist on the property? YES ® NO O
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 0
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 ® NO Q
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 Alteration(s) ❑ Roofing ❑
Or Doors E-1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding [0] Other
Brief Description of Proposed
Work: INSTALL WOODSTOVE IN EXISTING HOOKUP
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X _No
Plans Attached Roll - Sheet
6a. If New house and or addition to existina housina, 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
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as wner/ uthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the IS1 my knowledge
and belief.
Signed under the pains and penalties of perjury..
Print N
ov w I -
nature of Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Swerv or
/
Name of License Holder : A " i J
\7/y�
VE ✓ '
Not Ap plicable ❑
1 / /3
License Num er
16
Ad s _
7 q
Expiration bate
Signature Telephone
9. Reaistered Home Improvement Contractor:
Not Applicable ❑
Company Name
Registration Number
Address
Telephone
Expiration Date
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.
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. 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 -near period shall be co 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