12C-119 ¥7 BP- 2011 -0032
GIS #: COMMONWEALTH OF MASSACHUSETTS
% Bl_ock:'12C -119 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 -0032
Project # JS- 2011- 000054
Est. Cost: $600.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SEAN JEFFORDS 074539
Lot Size(sq. ft.): 10846.44 Owner: ROBINSON ROBERT C & MARY LOU ROBINSON
Zoning: URA(100 /� Applicant SEAN JEFFORDS
AT. 96 RICK DR
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (416) 529 -0544 WC
EASTHAMPTONMA01027 ISSUED ON. 711912010 0:00:00
TO PERFORM THE FOLLOWING WORK.-AI SEAL W /SPRAY FOAM,REPLACE DRYER
DUCT,WEATHER STRIP DOORS
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 7/19/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2011 -0032
APPLICANT /CONTACT PERSON SEAN JEFFORDS
ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON (416) 529 -0544
PROPERTY LOCATION 96 RICK DR
MAP 12C PARCEL 119 001 ZONE URA(100) //RI/WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: AIR SEAL W /SPRAY FOAM,REPLACE DRYER DUCTWEATHER STRIP DOORS
New Construction
Non Structural interior renovations
Addition to Existin
Accessory Structure
Building Plans Included:
Owner/ Statement or License 074539
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFgRMATION 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 Pemut from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Sig re of Build ng ffi al 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.
Version 1.7 Commercial Building Permit May 15, 2000
i -.._� ti.flepartnentuseonly
City of Northampton Stafus Permit
•Building Department Curb Cut/Dn veway Permit
212 Main Street serer/septl
" 'c Availabtllty,
Room 100 Water/WeN Availability
1;L 1 3 Northampton, MA 01060 Two Sets of Structural Plans
phone 413 587 -1240 Fax 413 - 587 -1272 Plot/ Plans
Other Specify
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address
This section to be completed by office
Map Lot Unit
�w re r2d- -G Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
F10 AelX6
Name (Print) Current Mailing Address:
Signature A r A A I Telephone
2.2 Authorized Age t:
Name (Print) Current Mailing Address
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. f+Y✓JC b'i 4 ? . (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 -
Ot
6. Total = (1 + 2 + 3 + 4 + 5) Qd Check Number
This Section: For Official Use Onl
Building Permit Number Date
Issued
Signature:
Buildinq Commissioner /Inspector of Buiidinqs Date
Version 1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enter a brief description here.
Of Proposed Work: A I V d� G'S ' 91 414 10`4i tk c "Y4-- ✓ G
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A El
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Reside ntial ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑
U Utility ❑ Specify
...... m _ .....
M Mixed Use ❑ Specify.
S Special Use ❑ Specify
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: _ ..._.__ Proposed Use Group. ... _W..........,. _._..,._ _._. - --- -
..,, _,,....,
Existing Hazard Index 780 CMR 34) _.,,,_..._ __..._ Proposed Hazard Index 780 CMR 34)
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICEUSE ONLY
Floor Area per Floor (sf)
1 St _.
1
St
_, _...._... ._ . ,. ..,.. 2nd ..
2nd _......... _ -
3 rd
3rd _....,..._ . _ .._
_....,. _.., „ .. 4 u
4w_.. _.. __ ..... _ _,..
Total Area (so Total Proposed New Construction (sf)
Total Height (ft)
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ I Zone Outside Flood Zone❑ Municipal ❑ On site disposal system E]
Version 1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: _ . L R:
Rear
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 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW I&I YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
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 0 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 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version 1.7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
__.... Not Applicable El
Name (Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
bu........ .. ��.w -m _ �_. ,.. ._ ___.._.. .m...._
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
93 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
Version l.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 1,10.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No Q
SECTION 11 - 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 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.
c I`( 41au
Print Name
Signature of Owner/Ag4nk Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration
Signature Telephone
SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GL. 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
.= Office of Investigations
a =` 600 Washington Street
Boston, MA 02111
www. mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
_
Hanle ( Business /OrQanization/Individual): 0 t UI G _Q CU Y`"lJ j'I LrC;�(✓ V1
Address:
City /State /Zip: t r 6l MA 01 0 phone # 't I '�5 '5 2- - C S' �{
Are you an employer? Check the appropriate bog: Type of project (required):
1. I am a employer with 4• ❑ I am a general contractor and I
employees (full and/or part- time).
have hired the sub - contractors 6. New construction
2. ❑ I am 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.t
required.] 5• ❑ We are a corporation and its 10.❑ Electrical repairs or additions
officers have exercised their
3. ❑ I am a homeowner doing all work 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no f '
employees. [No workers' 13 R Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicatins such.
, Contractors 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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: I l VIL— V V L 2
Policy # or Self- -ins. Lic. #: " - 1` 2-- s Expiration Date:
Job Site Address: / k Cr /L A "e 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 $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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Ittvestigations of the DIA for insurance coverage verification.
I do hereby certify under the pa' a alties of perjury that the information provided above is true and correct.
Signature: � Date:` / C
L 1 1 Phone #: t 1 �2 C _ - 1 r 0
Official use onli Du not write in this area, to be completed by city or town official.
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 #: