23D-117 3040DC
0
Kherdian Bathroom
remove old bathtub, shower doors, tile walls,
sink, toilet
install new shower stall unit
new tile floor (50 sf), 1/2 walls (60 sf)
• new toilet
/ r new pedestal sink
j plumbing and electrical to code
m - _
Kherdian Kitchen
-
remove ironing board, upper cabs, counters
(° 4 new base cabinets
l 1 pantry cabinet
0 1 4 runs upper open shelving
new fridge
new dishwasher
new vent hood
new sink, faucets
4DB24 �' B33
built -in wall shelving at entry
17 If (34 sf) butcher block countertop
3 If (6 sf) tile counter top
4111 15 If (30 sf) tile backsplash, sink wall only
/ m electrical and plumbing to code
- ° save pre- finished oak floor
\",1 save range
11 o i
3040DC
LIVING AREA
291 sq ft
.. •.- The Commonwealth of Massachusetts
Department of Industrial Accidents
l— Office of Investigations
600 Washington Street
0 ==e Boston, MA 02111
6 * www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): ere vt To -P_
Address: ( -S ' etece >4 N — 1 - S
City /State /Zip: Pia i . e l d 0 D l %' O Phone #: `Y/ 3 6 y- c)33
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. El New construction
employees (full and/or part- time).* have hired the sub - contractors
2 I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub - contractors have 8. El Demolition
for me in any capacity. employees and have workers'
working Y p ty. 9. n Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 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
employees. [No workers' 13. ❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating 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:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: 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
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: � — c_. - -- '" Date:
Phone #: / / 3 - 6 3 Y - . 8
Official use only. Do 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 #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
-‘er o._ 'TO (---)/ 7370 *-/
License Number
010 70 ; I ; 0}j
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
�
e //
Company Name Registration Number
--)Ga f" h, c. H cif t ■ - • C v23'
Address Expiration Date
eil Telephone S ``
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 Sectio i 08.3.5.1.
Definition of Homeowner: Person (s) who own •arcel o'�'Ta7ttfenyhich he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwellin:, attached or detach&1estructures accessory to such use and/ or farm
structures. A person who constructs more than on home in a two - yea ' eriod shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Office. , on a form ac stable to the Building Official, that he/she shall be
responsible for all such work performed under the b i ' ding it.
As acting Construction Supervisor your presence on the • • ite 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 15 ' orkers' ompensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death • the Massachu' tts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under t•', permit.
The undersigned "homeowner" cert -s and assumes responsibilit for compliance with the State Building Code, City of
Northampton Ordinances, State d Local Zoning Laws and State o - Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ED Roofing ❑
rat Or Doors D
Accessory Bldg. El Demolition Il New Signs [0] Decks [p Siding [0] Other [0]
_
Brief Description of Proposed ,
Work: A J , n
' z- v - F j1- *' (A e 1z i . Aire , pi. t. Zbi n 1() ,4 rre,) rw il4 v i '2i'w
C . h et 7 1-/c o snjr %,
Alteration of existing bedroom Yes No No Adding new bedroom Yes - No
Attached Narrative Renovating unfinished basement Yes ) 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
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
I, 7/1-- L. (/ lc ('( 21) 1V as Owner of the subject
property
hereby authorize -_J c4 7 �? //z E
to act qp my belie! , i ,a-ti matters j relative to work authorized by this building permit application.
/ 117A -t � Zt_.{ rt--. ‘t'(-74-41 , Ili -- /r r
Signature of Owner Date
- } C r- r,..` 'To
--- res-k rL`3(✓f�
•
.
f JO - L I - /l
Signature of Own- /Agent - Date I
•
1
Section 4. ZONING All Infor Lion Must Be Completed ermit Can Be Denied Due To Incomplete Inform ion
Exis i Proposed Required by Zoni
This colum tiled in by
mg 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
parking)
# 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 Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES Q
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO
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
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 Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
RFCEIVED City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
LL, — 5 2011 Room 100 Water/Well Availability
orthampton, MA 01060 Two Sets of Structural Plans
or . e 3 Fax 413 Plot/Site Plans
Other Specify
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
Fe clo„f7.4. Map Lot Unit
f ro .s tor, Zone Overlay District
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
7)4 v ( All 6 : - /9//1 6 / •,*(6,. 44i 1
Name (Print) Current Mailing Address:
I 1-1 e
Telephone 7
Signature
2.2 Authorized Anent:
( re ) 5 '>7 , AA 01 01 0
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 •' - 3 (a) Building Permit Fee
2. Electrical - 0 00 (b) Estimated Total Cost of
Construction
3. Plumbing .. Permit Fee
f 0 0
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1+2+3+4+5) 5 /7
Check Number "
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File # BP- 2012 -0332 •
APPLICANT /CONTACT PERSON SERENA TORRY
ADDRESS/PHONE 158 PLEASANT ST PLAINFIELD (413) 634 -8088
PROPERTY LOCATION 196 FEDERAL ST
MAP 23D PARCEL 117 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out / �e ( S 1j 0 2 0 7 �
Fee Paid �
T Construction: REMODEL KITCHEN (CAB & COUNTERS) & ADD 2ND FLR BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 078904
3 sets of Plans / Plot Plan
THE F LOWING 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
emolition Delay
A I e v...4 r '. / -
CP- r aofB:- ding Offici.`
/ 7/
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.
196 FEDERAL ST BP -2012 -0332
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D - 117 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0332
Project # JS- 2012- 000472
Est. Cost: $37000.00
Fee: $222.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SERENA TORRY 078904
Lot Size(so. ft.): 10628.64 Owner: DOSTAL FLORENCE M ET AL
Zoning: URB(100)/ Applicant: SERENA TORRY
AT: 196 FEDERAL ST
Applicant Address: Phone: Insurance:
158 PLEASANT ST (413) 634 -8088
PLAINFIELDMA01070 ISSUED ON:10/6/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN (CAB & COUNTERS) & ADD
2ND FLR 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 10/6/2011 0:00:00 $222.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner