11A-033 4
BP- 2010 -1126
GIS #: COMMONWEALTH OF MASSACHUSETTS
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µ too k:, I IA - 033 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit # BP- 2010 -1126
Project # JS- 2010- 001378
Est. Cost: $85500.00
Fee: $513.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WILLIAM LYON 70501
Lot Size(sq. ft.): 29185.20 Owner: CASEY GEOFFREY H
Zoning: URA(100) / Applicant: WILLIAM LYON
AT. 31 EAST CENTER ST
Applicant Address: Phone: Insurance:
483 GALE AVE (413 ) 281 -5393
PITTSFIELDMA01201 ISSUED ON. 611012010 0:00:00
TO PERFORM THE FOLLOWING WORK.- CONSTRUCT 2 STORY 16 X 16
ADDITION(LIVING RM &BEDRM)CONVERT BEDRM TO BATH
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 6/10/2010 0:00:00 $513.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
City of Northampton
Building Department"
212 Main Street
Room 100
Northampton, MA 01060
_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
1.1 Property Address
This section to be completed by office
>
l Map: Lot Unit
tl 5
_r Zone
0 Vertay Distract
Etrri $t `I)18trtct CB:District
SECTION -2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
GEoF�1Z- y ff. C - A -IS 3 1 & er,4/re z sr- [eEp,
Name (Print) Current Mailin Address:
S -�'6 -/ 2 6
Telephone
2.2 Authorized Aaent:
Nam (Pri t) Current Mailing Address:
�67
Signature Telephone
SECTION 3 - ESTIMAT CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building A (a) Building Permit Fee
2. Electrical d b (b) Estimated Total Cost of
Construction from 6
3. Plumbing D Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection ?
6. Total = (1 + 2 + 3 + 4 + 5) p v" Check Number 700
This Section For Official Use Onl
Date
Building Permit Number: _Issued:
Signature: 7 r d
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
l Building Department
i
Lot Size ' �l a
t�
Frontage � 1
S
r Setbacks Front ZOE
Side L: 2tJ7: 1 R: L: R: E 1
Rear
Building Height? ---
i =_
Bldg. Square Footage j
Open Space Footage % ®C '0"
a{ (Lot area minus bldg & paved
t parkin
'
1. # of Parking Spaces _ t
1 '4
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
tch
NO 0 PON7 NOW YES
IF YES, date issued:' � cR : 4/1 -
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES
Pa e and /or Document #
IF YES: enter Book � 2 '� � � � g e � ,�
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW YES Q
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 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES I NO—#
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, pxcavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES In NO I
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 EJ
Or Doors 1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [I- Other [a
Brief Des ion ofp oposLd f L
4Z 72"
Work: J r
Alteration of existing bedroom - Yes No Adding new bedroom 7 Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
a. Use of building: One Family Two Family Other /
b. Number of rooms in each family unit: 2 Number of Bathrooms t
c. Is there a garage attached? /V o /
d. Proposed Square footage of new construction. Dimensions P
e. Number of stories? 2-- f/
f. Method of heating? Fireplaces r Woodstoves CTA► Number of each
g. Energy Co nservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes Y No. Is construction within 100 yr. floodplain Yes V No
j. Depth of basement or cellar floor below finished grade X 6 0 <XPr--
k. Will building conform to the Building and Zoning regulations? Y 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'
G� �FR� y �• c ' r Y as Owner of the subject
property
hereby authorize L
to act on my behal in I afters relative to work authori d by this building permit application.
e• i o
Signature of bat
I /�i'/� -1 ` �r as Owner /Authorized
Agent hereby declare that the statement &d information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Sig d nder the pains and penal 'es of peg
Print Nam
na ure of ner /Agent bate
SECTION 8 - CONSTRUCTION 'SERVICES
8.1 Licensed Constructio Su rvisor: Not Applic 0
Name of License Holder /C.L/ *1 "' �� S
� License N tuber
Add ss Expiration Dat
4
Signature Telephone
S.ecitsterEd[ofne lriiairi�itelKitttracfor �� A�' Not Applicable ❑
/6, 301
Cogivapy Name / Registration Numb 7 oo a
Address Expirati n Date
____Telephone,
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(61)
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 bull d'ng permit.
S igned Affidavit a e es....... ---- T1o......
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 hom eowner.
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
jy Y i T
The Commonwealth of Massachusetts
Department of Industrial Accidents .
*51 OLV Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Piumb.ers
Applicant Information ^ Please Print L " 'bi
Z 7V 7
v
Name ( Business /organizatiow7ndividuaI):. C �/
Address: 77 eLE 4 L14e /� t 7'���1 G� Xsf=
City /Statemp: /i i _ 7S, A4,8. Phone. #: �� O L
Are you an employer? Check the appropriate box: Type of project (required) :.
1. Q I am a employer with 4.- Q I am a general contractor and I
loyees (fall and/or part- time).
: have hired the sub—contractors
6. New construction
2.. M I am a sole proprietor or partner- listed the attached sheet, 7. JS Remodeling
ship and have no _=pioyees Tie sub- cctors have .8. Q Demolition
working' for -me in any capacity. employees and have workers'
[No worleets' comp: insurance comp. msunMcc - #._ �uIldn2g a�ditlOn
required:] 5. Q We are a corporation and its 10,0 Electrical repairs or add'ition's
officers haveercse their
Plumbing or ad
g ditions
3. Q I am a homeowner doing all work Gid f 11. Plumb' r
myself (No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required:] t c. 152, § 1(4), and we have no "
--
comp. insurance required.}.
'Any applicannt that checks box #1 must also fill out the section belowshowing dneirwori=s'- compensation policy information.
t Homeowners who submit ties affidavit.indic:ating they are doing all work and then him outside contractors must subrmt a new affidavit indicating such.
IContractors that check this box mt attached an additional sheet showing the name of the sub- conttactm and state whether or notthoscartides have
employees. .If the sub- coutnactors have employees, they must provide their won ' comp. policy number.
lam an employer that u providing workers' compensation insurance foa my employees Below is the polity and job site
information.
hmnance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City /Stafe/Z .
Attach a copy of the workers" compensation policy declaration - (showing the policy number. and expiration date).
Failure to secure coverage. as required under Secti on 25A ofMGL c 152 can lea&to the impod – d n ofcr'iminalI penalties of a
Sine up to $1,500.00 and/or one. -year imprisonment, as well as civil penalties in the form of a STOP WORKORDER and a the
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
Tnvestisatioris of the DIA fo insurance' coverage "vii ifrcat on
I do hereby un& enaltres ofperfuiy that the information provided.nb aadcorr __
Si mature A
Phone
Official use only. Do not write in this area, to be comp by city or town official
City or Town: NrmitUcense #
Issuing Authority (circle one):
.1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other F
Contact Person: Phone #•
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 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
. nal tinilding inspeMioir. - - --
building department requires these inspections before the work is concealed, failure to
secure these insDections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the 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
�ermits 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 tome.
Date
Address of work
location
File # MP- 2010 -0070
APPLICANT /CONTACT PERSON CASEY GEOFFREY H
ADDRESS/PHONE 31 EAST CENTER ST (413) 695 -8125 Q
PROPERTY LOCATION 31 EAST CENTER ST
MAP 11A PARCEL 033 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ONING FO FILLED OUT 2 :2 a .,I ,�
Fee ai
Building Permit Filled out
Fee Paid
Typeof Construction: ZPA - 2 STORY 16 X 16 ADDITION
New Construction
Non Structural interior renovations
Addition to Existing
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
INF >RMATION 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
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 the Office of
Planning & Development for more information.
4
File No. 70
Plea plyp- ei or pr nt;'All information and return this form to the Building
Inspector's Office with Wwr$15 filing fee (check or money order) payable to the
City ofNorthampton
1. Name of Applicant: C ii C cLS e U
Address: > ` CL.-C V C eK+e V Sj ep 1 S Telephone: y l 3 ' Co Q
0 L0G5
2. Owner of Property n4 ca. ' e C"
Address: , YYL _ Telephone: ' e
3. Status of Applicant: Owner Contract Purchaser Lessee Other (explain)
4. Job Location: 3k
5. Existing Use of Structure /Property: nn P
6. Description of Proposed Use /Work/Project/Occupation: (Use additional sheets if necessary):
16 ( k 16'
7. Attached Plans: Sketch Plan Site Plan ✓ Engineered /Surveyed Plans
8. Hasa Special Permit /Variance /Finding ever been issued for /on the site?
NO DON'T KNOW YES IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and /or Document #
9.Does the site contain a brook, body of water or wetlands? NO _1/ DON'T KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , date issued:
(Form Continues On Other Side)
W:\ Documents\ FORMS\original\Building- Inspector\Zoning- Permit - Application- passive.doc 8/4/2004
10. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location:
11. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common
plan of development that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION
This column reserved
for use by the Building
De artment
EXISTING PROPOSED �1
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Building Square Footage
% Open Space: (lot area
minus building & paved
p arkin g
# of Parking Spaces
# of Loading Docks
Fill:
(volume & location)
13. Certification: I hereby certify that the information contained herein is true and accurate to the best of
my knowledge.
Date: Applicant's Signature
NOTE: Issuance of a zoning permit does not relieve an applicant's burden to comply with all zoning
requirements and obtain all required permits from the Board of Health, Conservation Commission,
Historic and Architectural Boards, Department of Public Works and other applicable permit granting
authorities.
W: \Documentsl PORMS\original\Building- Inspector\Zoning- PeMlit- Application- passive.doc 8/4/2004
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