39A-017 t
i 1 WRIGHT AVE - 2ND FLR BP-2011-0288
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 39A - 017 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- 2011 -0288
Project # JS- 2011- 000480
Est. Cost: $16400.00
Fee: $98.40 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 6185.52 Owner: GOLDSTEIN ROSEMARY
Zoning: URC(100)/ Applicant: GOLDSTEIN ROSEMARY
AT: 11 WRIGHT AVE - 2ND FLR
Applicant Address: Phone: Insurance:
13 TRUMBULL RD (413) 584 -4549 ()
NORTHAMPTONMA01060 ISSUED ON:
TO PERFORM THE FOLLOWING WORK: REPLACE SHEETROCK & UPGRADE HEATING
& ELEC - Smokes and COs must be updated to current code! - All construction must be
inspected prior to being covered !!
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 Signature:
FeeType: Date Paid: Amount:
Building 9/30/2010 0:00:00 $98.40
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP- 2011 -0288
APPLICANT /CONTACT PERSON GOLDSTEIN ROSEMARY
ADDRESS/PHONE 13 TRUMBULL RD NORTHAMPTON (413) 584 -4549 0
PROPERTY LOCATION 11 WRIGHT AVE - 2ND FLR
MAP 39A PARCEL 017 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out / '5? //°
Fee Paid `�
Tvpeof Construction: REPLACE SHEETROCK & UPGRADE HEATING & ELEC
New Construction _ - •'∎ . , t` f ^. r ' sr r PP' •0 i d i`tA(ZIt'TT (.410E:
Non Structural interior renovations ; _ - r A LL. Cot.) r t' (Z AA CT l W / nit iA ST 6 E
Addition to Existing ("J.s Fiff` b EIs qe r< N (C' Jte -fL4;J'�
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOXVIATION PRESENTED:
L , pproved 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
•
930/ 0
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.
Department use only
City of Northampton Status of Permit:
Department Cut ;Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
r ,� i
Room 100 Water/Well Availability"
1 Qrthampton, MA 01060 Two Sets of Structural Plans
S� e phone 413 - 5871240 \Fax 413-587-1272 1272 Ptot/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:
/ / k'/ 6. T , 5 1 e/ 4- (2 F!) Map Lot Unit
it 0 /3 f g ' Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
hC)ctC iU ( CI sA - C,., 3 Tr;kM \3ULc_ 1 Norn--04 -9.Tz,v it-Z
Name (Print) Current Mailing Address:
9 Telephone
Si L _ S l t i 7 c' J
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature 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
2 Q U• Construction from (6)
3. Plumbing Building Permit Fee
2_3"
4. Mechanical (1-IVAC) .1 6 c c c�
5. Fire Protection , 17_,)
6. Total = (1 + 2 + 3 + 4 + 5) : i j j1- C c co_ Check Number 1/ /if # lip
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector 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
(It C L CA Building Department
Lot Size .A) A CLC AY: Vt_t tl-kz
Frontage
Setbacks fl
Side R:I /
L:_
Rear
#3 I
_
. .
Building Height
Bldg. Square Footage Ak„, 1 76, % FT"
Open Space Footage
(Lot area minus bldg & paved 1/.2g
parking)
# of Parking Spaces
7
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 0
IF YES: enter Book Pagel and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO %) DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
0 , Date Issued:
C. Do any signs exist on the property? YES 0 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 0 NO
IF YES, describe size, type and location:
E. VVill the construction activity disturb (clearing, grading, exc vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
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 14
Accessory Bldg. ❑ Demolition El New Signs [D] Decks [ Sid [D] er D]
Brief Description of Proposed S r dafiAS ` '' ho +I�0 4' anc( f► r, S p SCle t a 0 - room s.. r 4 tie)
Work: "441 n jn a fru k S
ogfin S st toi , a vpr acLi eac-}ric . .
u ' htrinc) 4A ¢1 ackv -,ci q „ S co, whow',11 pwl(pe.r/nits.
Alteration of existing bedroom Yes X No Adding new bedroom Yes �< No
Attached Narrative Renovating unfinished basement _ Yes y 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 A\ /CA_
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
I, 1? , f'Qs.ft n , as Owner /Authorized
Agent hereby declare at 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.
fal S? rinCve / 144 S 1"12 t .,
Print Name
or
z //v
Signature of Owne gent Date
SECTION 8 • CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
S. 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 ❑
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.
i
Homeowner Signature
' -,
, . .
, s '
The Commonwealth of Massachusetts
• Department of Indust Accidents
..=?..-„_,—.....
Pk
ir si
z =....,T.....7 E ' Office of Investigations •
=_. ,- ..
600 Washing Street
Boston, MA 02111
www.mass.govidia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Legibly
Name (Business/Organization/IndivichinD: Q_ose ill a .t y G el
• Address: t r ( .??0 •._.'c••)
City/State/Zip: I\)c) 11--T-14at)-11, 2 gi/L) /1/4-ill- °C giOne.#: 41 3 —5 St( —5F
il
Are you an employer? Check the appropriate box: •Type of pi (required): I
1. C) lam a employer with 4• 0 I am a general contractor and I
6. 0 New construction
have hired the sub-contractors
employees (full and/or part-time).*
listed on the attached sheet 7. ing,
2. 0 I am a sole proprietor or partner- • These sub-contractors have. 8. 0 Detnolidon
ship and have no employees
employees anti have workers' ..
working for me in any capacity. 9 0 Buildrag aaditiOn
[No workers' comp. insurance
requirecLj 5. 0 We are a corporation and its 10 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have 4zercised their 11Z Plumbing repairs or a Aditions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13 .h6.1 Other
comp. insurance required.1
*Any applicant That checks box #1 must aLso fill out the section below showing their worlcers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
1 Contractras that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees, they must provide their workers' comp. policy number. =
lam 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/Sta&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 25AnfMGL c. 15Z can lead to the impositiOn of criminal penalties of a
fine up to 51,500.00 ancl/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK-ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Of5ce of
Infeiriantioni Of the DIA for insurance coverage imiificatiOn.
_ I do here.b_y certifi under the pains and penalties ofpajtay that the information provitkirabove_ir:irrii_cindc;3rrect ___
..
Phone #: 1 // 3 "S -- tcYL5 • •
Official use only Do not write in this ai-ea, to be completed by city or town'offzciaL
• City or Town:
'• Permit/License #
Issuing Authority (circle one): . ,
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
1
HOME OWNER EXEMPTION ACKNOWLEDGEMENT.
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. 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 building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction m 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 backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. 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 occupancy
until the work can be inspected.
Tithe 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
i:lermits 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 ow /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date 9/ 2 91/ 0
Address of work
location // Gt!'2 /Gft j *'E ( 2"r
/rXh2 -7►tr AiP /7�.v / / 0106 o