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17C-111
` 32STILSONAVE BP- 2011 -0618 GIs #: L COMMONWEALTH OF MASSACHUSETTS Map - Bloc 17C - 111 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 -0618 Project# JS- 2011 - 001006 Est. Cost: $21000.00 Fee: $126.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor. License: Use Group: NICHOLAS JONES 066878 Lot Size(sq. ft.): 11238.48 Owner: JONES JEANNIE Zoning: 1TRB000)/ Ap p licant: NI_C_H_ J ONES AT. 32 STILSON AVE Applicant Address: Phone: Insurance: P O BOX 515 (413) 665 -7927 WHATELYMA01093 ISSUED ON :1/13/2011 0 :00 :00 TO PERFORM THE FOLLOWING WORK .- REMODEL KITCHEN & REPLACE BATH FIXTURES - OPEN WALLS MUST BE INSULATED & INSPECTED POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of F D iring .P.W. Building Inspector ��$ �/ 6 Re ' -' Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: n j Final C pl Q ~� F ., Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: C — It Final: Smoke: Final: THIS PERMIT MAY BE REVOK D HE CITY OF THAMPTON UPON VIOLATION OF ANY OF ITS RULES AND IR .ewr. Certificate of Occu an Si ature: FeeType: Date Paid: Amount: Building 1/13/20110:00:00 $126.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP -2011 -0618 APPLICANT /CONTACT PERSON NICHOLAS JONES ADDRESS/PHONE P O BOX 515 WHATELY (413) 665 -7927 PROPERTY LOCATION 32 STILSON AVE MAP 17C PARCEL 111 001 ZONE URB000)/ 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: REMODEL KITCHEN & REPLACE BATH FIXTURES New Construction I I - Non Structural interior renovations ( i J Addition to Existing Accesso1y Structure Building Plans Included: Owner/ Statement or License 066878 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INPRMATION 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 el y Sig re of B ildi g fficial 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. City of Northampton Building Department - 212 Main Street Room 100 Northampton, MA 01060 phone 3'-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 / Lot llnit � Zane O�reriay pstrrcf Etrrr st ©lstrlct . CB. District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Recor f J� 1 O �J�(,�1�^ Name (Print) Current Mailing Address: 11 ,3 ---- -- c �r —_ Telephone Signature 2.2 Authorized A ent: s U'K T15 Yk, O LM Name A Current Mailing Address: V1 Of 7 �z7 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building p�tJ (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 6. Total = 0 + 2 + 3 + 4 + 5) 017 Check Number ff 8 --' This Section For Official Use Onl Date Building Permit Number. Issued Signature: Building Commissioner /Inspector of Buildings Date /V' Secti0n 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 I' Frontage € Setbacks Front -- Side L• R• L : R• Rear f ----'_ Building Height -- Bldg. Square Footage % � Open Space Footage % (Lot area minus bldg & paved p arkin g) # of Parking Spaces ---� -- Fill: j ( volume & Location 1 A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KN OW (D YES Q IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Q 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 Q 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 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 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 0 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) r Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding [0] Other [a Brief Description of Prpp sed P �r Work: p o 11na" kr '1 f� n �c�t� 1 40v `R p( Alteration of existing bedroom Yes b_ No Adding new bedroom Yes P C No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet g .R1 ifint p ,�, lfFe6G:I 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 !- Td BE COMPLETED :WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'. 1, 2d I nf'c Z_"_ ft s as Owner of the subject property hereby authorize /YlL/! S JGrL� to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, / " if WG h{_ `i - d 6 ! 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 thp pai s and penalties of perjury. irw ` T Print Name V / 6 Signatur o er/ gent ate SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Sue isor: Not Appli Name of License Holder J 6 �/7 L -7 D License Number s CLS&jA e lAth s % 7/261 Address Expir ta�Date ✓� �' Signature Telephone tai n ilB Not Applicable ❑ on Company Name Registration Number Address Expiration Date Telephone 11q 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....... tQA No...... ❑ 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 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. Homeowner Signature s T L y y L' The Commonwealth of lassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov /dia - Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information Please Print L • 'blv Name (Business/Organization /Individual):. Address: L75 '; PIA City /StatelZip: ` , Ott. oAo43 Phone. #: 113 7V-,Z7 Are you an employer?. Check the appropriate'box: Type of project d (required) . � a di 1. I am a employer with 4.. [] I am a general contractor and I employees (full and/or part time). * have hued the sub- contractors 6. El New construction 2_[�(I am sole proprietor or partner- liste __.on the attached sheet. 7. . Remod eling ship and have no a *Ioyees These sub - contractors have 8. 0 Deao,'ilion working for me in any capacity. eavIoyees and have work=' troy tom•., workers' comp InSiirancC _. COII�. menranrp #. 9 .. required] 5. E We are a corporation and its 10.0 Electrical repairs or additions or additions 3.0 I am a homeowner doing aII work officers have xercised their epans 11.0 Plumbing r myself insurance [No workers' comp. right of exemption per MGL 12. Roof c. no insurance required t � 152 (/ � 114 ) , and we have '. '' employees. [No workers' 40 Other comp. insurance requited.]. 'Any applicant that checks box #1 anist.also fill out the section below showing their workers' cotnperrsstian Policy mf ©tmatirnt: t Homeowners who submit this afdavit.indicating they are doing all work and then hire outside contractozs trust submit a new affidavit indicating such.' �Contactnrs that check this box must attached an aMt m l sheet showing the name of the sub=contractors and state whether or not those-entities have employees. 7f the sub-contractors have employees, they must provide their workers' coam- policy number. I am an employer that isproviding workers' compensation insurance for my employees Below is thepolicy and job site inf Insurance Company Name: . Policy # or Self-ins. Lic. #: Expiration Date: Job Site Address: City /Stafe/Zip: Attach a copy of the workers' compensation policy declaration page'(showing the policy number and eapirahon date). Failure . to secure coverage.as regtiired under Section'25A'ofMGL c 15Z can Iead "to the imposition Of' " penalties of a fine rip to $1500.00 and/or one- ye2r 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 co py of this statement may be forwarded to the Offic of e Invesfisations'ofthe bIA for irtsurauce covera.ee veriizcation.� ' - -- � -�•� -� -�M --� __..; I do hereby certrfy the pains and ofperjuiq M& information providedabov ' - aad_coriec S i titre: ate: / a 1 Phone #: - 7:G — Official use only. Do not write in this area, to be completed by cidy or town o ciaL City or Town: PermitUcense # Issuing Authority (circle one): .1. Board of Health 2. Building Department 3. City/Town CIerk .4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: