24D-170 (2) File # BP- 2011 -1085
APPLICANT /CONTACT PERSON SERENA TORRY
ADDRESS/PHONE 158 PLEASANT ST PLAINFIELD (413) 634 -8088
PROPERTY LOCATION 211 STATE ST
MAP 24D PARCEL 170 001 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
Fee Paid
Typeof Construction: REPAIR FIRE DAMAGE
New Construction
Non Structural interior renovations
Addition to Existin
Accessory Structure
Building Plans Included:
Owner/ Statement or License 078904
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
Demol' ' Delay
Si a 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.
.r
f City of Northampton
5
Building Department
2 Main Street
oom 100
v� No ampton, 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
Map L6� I1g1t
_-- �otte Ov$rtatl pistrict
stotr;ct = CEVD161 rFet
SECTION 2 - PROPERTY OWNERSHIPLAUTHORIZED AGENT
2.1 Owner of Record {�
M(rint) / Current Mailing Address:
Telephone
all
2.2 Authorized Agent:
D�) (C �9 G a s A 6
Name (Print) Current Mailing Address:
,ar g — n5tdre Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building l0ermitfee
4. Mechanical (HVAC)
5. Fire Protection
0; lip
6. Total = 0 +2+3+4+5) Chedc Number J/ 4 r o
This Section For Official Use Onl
Building; Permit Number. Date Permit
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
Building Department
Lot Size a i
Frontage _ 1
Setbacks Front
Side L: _i R: _. _i L: R:
Rear - ---- -'
Building Height r--- —
i
Bldg. Square Footage % �
Open Space Footage % --- 7
(Lot area minus bldg & paved L
par
# of Parking Spaces
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO ® DONT KNOW 0 YES
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 Boo Page 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 ® NO I
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
IF YES, describe size, type and location:
E. Will the construction activity disturb (Gearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTIONS- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ T Zflng ❑
Or Doors �5_
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [0] Other [p]
Brief Description of Proposed.'
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
�41i11RLliits k�fl �t` .11?fillx:
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
Energy C C om lian 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'
I, 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, as Owne uthorize
ge declare that the statements and information on the foregoing application are true and accurate, to the best kr ovvledge
elief.
Signed under the pains and penalties of perjury.
Print Name
f 4 /'
Signature ner gen Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Superviso Not Applicable ❑
Name of License Holder: C I, U-1 �-�� c�'" 7� { ` G� T 0,19
License Number
Address fG 5 — Expiration Date
7/
Signatur /-, Telephone _
q Qs[l[ r�s/17/xf - snna li�g�B�iD1tICtot". ;0 Q , `�,_,� Not Applicable ❑
Company Name WINDOW WORLD Registration Number
56 Di mock Street � ` J J--
Address Leeds, MA 01053 Expiration Date
586 - 8712 Telephone
SECTION 10- WARKERS' COMPENSATION INSURANCE AFFII3l#VIT (M.G -L. c. 162,§25C
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.
igne avt a e es....... U 0.. ....
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 sha 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 buildine p ermit.
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
The Commonwealth of Massachusetts
Department of Industrial Accidents .
fn
Office of Investigations
600 Washington Street
Boston, MA 02111
:v www mass gov1&a
-Workers' Compensation Insurance Affidavit:.Builders/ Contractors /Electricians/PIumb.ers
Applicant Information Please Print Legibly
Name ( Business /organiiadon/Individuat): WiNnOW WORT )
56 Dimock Street
Address: Leeds, MA 0!053
City /StatelZip: S one. #:
Are you an employer? -Check the appropriate'box: Type of project (required):.
1. [❑ I am a employer with 4.. I am a general contractor and I 6. New construction
employees (fall and/or part-time). # have hired the sub- contractors
2 — 1 am a sole proprietor or partner- listed f e.attached sheet. 7. ❑ Remodeling
`` ship and have r_o: loyees These sub - contractors have. .8. [] Demio;ition
working for me in any capacity. employees and have worlors'
9 �tul '
addtoon
workers COMP #:.. II
r egua,
5. [f We are a corporation and its 10.0 Electrical repairs or additions
. ed officers haveercised their I1.
13. 0 I am a homeowner doing all work xx ❑ Plumb - mg - repairs or additions
myself [No workers' comp right 6f exemption per MGL 12.0.Roofrepairs
insurance req uired.] t c: 152, § 1(4), and we have no
ees. Vii o wo
comp. insurance required.}.
'Any applicant -that checks box ##1 must also fill out the section below showing theirworkers' cortpcnsation policy mformatiaL
t Homeowners who submit this affidavit.indicxting they we doing all work and then hire outside contaa&tots must submit ' a new alUdavit indicating such:
=Contracts s that check this box must attached an additional'shed showing the name of the sub= contraebvts and state whether1or not:th= emities have
employees. 'If the sub - contractors have employees, they must provide their work=' comp ..policy number.
I am an employer that is providing workers' compensation insurance for. my employees Below is the policy and jab site
information.
Insurance Company Name: .
Policy # or ; Self ins. Lic. #: Expiration Date.
Job Site Addres C' /State/
ri3' gyp=
Attach a copy of the workers'"compensation policy declaration ae
(showing the policy number and iration date .
Failure . to secure coverage. as required un&i7 Section 25A - bf M'GL c 152 sari leid flie imposition of cjimm I penalties of a
fine tip 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. a day against the violator. Be advised tat a copy of this statement maybe forwarded to the Office of
Lnvestit?afions of the DIA for insura ace` coveraze verifica#ion _
I do. 7zereby certify under the pares and penalties ofpeunry that the in ormation rovided abavE_is�^iie :sad cvrrec�
f p _
Si tire:
Phone #: 5 le �?
Official use only. in to Do not write this area, be comp -
by city or town o ff ural
City or Town: PermitUcense #
Issuing Authority (circle one):
J. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #•