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File # BP- 2006 -0903
APPLICANT /CONTACT PERSON Roger Clark
ADDRESS/P,HONE P 0 Box 34 LEEDS (413) 584 -1170
PROPERTY LOCATION 64 ICE POND DRIVE
MAP 37 PARCEL 106 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out / Q
Fee Paid 5/ ; J y9J
Tvpeof Construction: CONSTRUCT 12 X 20 SCREEN PORCH & 12 X 20 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
O wner/ Statement or License 021310
3 sets of Plans / Plot Plan
THE F LOWING ACTION HAS BEE TAKEN ON THIS APPLICATION BASED ON
IN 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
Permi rom Elm Street C. 'ssion
-Ars.....4 ■'' /- ' 4. /
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 Office of
Planning & Development for more information.
O,c5tiAMPTO �
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7' DEPARTMENT OF BUILDING INSPECTIONS =_._.-z-_---_-=' - - - L
INSPECTOR 212 Main Street • Municipal Building
'M 5 •
Northampton, MA 01060 °`•
e'
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his /her construction sups: sor. 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 -any 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
concealed), insulation inspection (if required) and a final building inspection-The
building department requires these inspections before the work is concealed, failure to
secure these inspections 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
permits 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 to me.
Date
Address of work
location
p4' TO
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<< Gri z� Northampton • 1
',,• •
_ - E �lcoakrhnttua •
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_
' D ' EPARTMENT OP BUILDrrc INSPECTION'S
212 Main Street ATunlup.nl Building
Norlhamplon, Mass. 01060 r'
•
•
ter' O RT C IZ' S C O i1ZP EN SATIO.N • ONz S URAN C.1', AFFEDAvyr
•
_ D G- C - : P. (.1._./4 R . --
(li ccnsxJper rni tttx )
with a principal place of business/residence at:
d 3 * . / E Sr t - l o R A / c - c - _ , /V a /OG. (phone) z113-5
(srrr_..t/cir, /sutchap) dA— _
do hereby certify, under the. a_ins and penalties of perjury, that L-11 � s86 /`/g/
( ) I am an employer providing the followine! worker's cornoensanon coverage For my
employees working on this job:
•
(L�sur - mac Coo v) - (Policy N cr) pirat or. Due)
-
( ) I am a sole proprietor, general contractor or homeowDer (title one) and have hired
the cone actors listed below who have the `olio vi worker's compensanon policies:
•
( -Naspc of Contractor) (In .urancc Comnpany /Polic, NurniKr) ( `pirauon Date)
(Name of Connaelor) (lrsuran Company/ Policy Ntunc-r) (17. piranon Dais)
-
(Name of Connaelor) (Lnsluane_ armun } - /Policy N:ls r) (Expiration Daic)
(Name of Contractor) (Insurance Company/Policy Numb -.r) (Expiration Date).
(nc.ic3 d; noel c�irnce=ta --c w a,cu& .aforroa -i pcu.iniac to .11
{1 I am a sole -proprietor and have no one worming for me-
( ) I am..a home owner performing all the work myself.
NOTE: pies: be "wart du: we:Do 6c voc m '- o =ploy pc-..00 co do rc eir work on . th. of
mt ta=rt: thec two t=iJ in wh:Lth the 150moo*wo cc oo the IIoua6 = tbe-co z: cot —1}y eel -:d-cd to be
etltplo - - ti - the . "em r- -,. ft= (GLI152.a 1(5)). pif - by " boamat fc : G =x a- pc:aa r=-y evid=3x t1 c
of co e:3Ioyer under tiw W or e!a Comtp.omuoa Ace
I uadcr..,.ad that a copy of thi, cs' ®ma =ay be forwnrded to the D ,zmcca of Iodo.:si i A. odct,' Of Soo of 4=w - woo. for lb.
cove -iSc vcif tctioo ri the: L - iltac to £C ire'covcrr o . - e tads soc..ion 25A of 1.iCIL 152 e3a Ice to the iapesaioo of cicoiru1 p"' • t
CO3331. of a fiat .1 to S 1300.00 azdfor of up to oat yt=r Lod d vii pca.tia to 6c form of a Stop Work Otdc cod a
fizz orS100.00. p rix
—.
For -
Pcrmt[ Nt1ID�
3/j y�d i.tor)- -- Lot
Signat ir of Licars ../Permute oe - -
SECTION 8 - CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor: nn ,p L . Not Applicable ❑ -
Name of License Holder : P06 e : L L4 R h o a /af
License Number
Po, aox .19 1 -Etj /74 i> /0..C 5 /o6
Address / Expiration Date
e_634/,_
Signature Telephone
9 Berns eredl ome ii pra�remenl ontracfor: _, . x „;3, 1 , #. - - Not Applicable ❑
(O�-Er (', CL A r? A /ol g'? 1
Company Name Registrat N umber
P• o, Bo-c 3 y L L D S 414 d/63 Va_Ipz
Address Expirafion D to
TeIephoneff/33 /y9/
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 V No ❑
I 1 'y om nereh nu
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
r
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [l Addition El Replacement Windows Alteration(s) L 1 Roofing n
Or Doors D
Accessory Bldg. [Ti Demolition ❑ New Signs [D] Decks [® Siding [D] Other [D]
Brief Description of Proposed )\- Work: / a 1C ?O S c t'ec�,tcd /0/' X a-0 D e dC
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes p/' No
Plans Attached Roll - Sheet s/
47! i Ne l se tired cor dif t e aastiiiTk ioasl q. comuiete the o` I[ q:
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? ✓ e s 486
J
d. Proposed Square footage of new construction. 5A' Dimensions f X'.0 F ]Z K20
e. Number of stories? / K C_
f. Method of heating? /v` /9 Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. 7 /V•4 Masscheck Energy Compliance form attached?
h. Type of construction wca
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 p ) rr 5 y j
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
Yo , as Owner of the subject
property
hereby authorize ��'� — � r /
to act on m be If, in a matters relative authoriz d by this building permit application.
3 /' 3/04,
Signature er ti Date
I,
(06--g t2 f , 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.
a E 12 P. L i r°
Print Name
/ 3/iY/O
Signature of Owner /Agent Date
Section 4. ZONING All Informatibh Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning ' ✓
This column to be filled in by U
Building Department
�% qa - 0 5 i. pi, sKm�
Lot Size �
Frontage ���' , ' S ei rt '
Setbacks Front I F
Side L koP R:' /00' ? L : ' 1,0"! R: , D ' / — ._/7. 6Q0
Rear fir± '
•
Building Height 3i i , f,Aly.14 Lam_ /
Bldg. Square Footage 63'00 I I a • 3 1 % 10.5 3'0; d.3.5''
Open Space Footage %
(Lot area minus bldg & paved 360), SJCI ;y7, ? i K.l, . 9t I `2
parking)
# of Parking Spaces M`
Fill:
(volume'& Location) - � -
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
i
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Pages ' 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 i NO 0
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 0
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 r NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Departmentuse only
City of Northampton Sta't„ubfPecmil n
Building Department cu ®vsnra
212 Main Street
1364v-et ati•° aik�l �� ti
Room 100 �` " e '
Northampton; MA 01060 • e g � Pa 4 1 . ;g `4-- . " ��
phone 413 - 587 -1240 Fax 413 - 587 - 1272 ®� � � � ��
nth " °
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: �; Th is section to be � cocnpleted by fficoe
• M ap - Lot ? h Unit.
Zon Oveirl D
•Elm S t District _ CB D�sinct
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: _
Y V6n�e - 1 '7 / �a Or /r01/4.' - /'114-1-‘ - vI e 6 L
Name (Print) - �� Current Mail Address:
y - 3 a
/ LA .,,,_..e Telephone
Signature
2.2 Authorized Agent:
�' 6-t fk I `' G i-4-R K �6 0 X 3'1 L E S� s j /9A 1J /d6-3
Name (Print) Current Mailing Address:
�. t.'(/----1--- y � 3 — sic --- J y9 J
Signatur Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
comp leted by permit applicant
1. Building D, 00 (a) Building Permit Fee fh,, OU loo a
2. Electrical (b) Estimated r Total Cost of X 2 0 O v
Construct f (6) '
3. Plumbing Building Permit Fee
'4 /00.0d
4. Mechanical (HVAC)
5. Fire Protection
_.1,4o � O i?
6. Total = (1 + 2 + 3 + 4 + 5) ) Check Number ' S l # � � lJ` 0
This Section For Official "Use Only
Building Permit Numbed I sue
Issued:
Signature:
Date
Building Commissioner /Inspector of Buildings
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BUILDING INSPECTION LABEL
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64 ICE POND DRIVE BP -2006 -0903
• GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 37 - 106 CITY OF NORTHAMPTON
Lot: -001
Permit: - Building
Cateeory: BUILDING PERMIT
Permit # BP- 2006 -0903
Project # JS- 2006 -1382_
Est. Cost: $20000.00
Fee: $100.00 - PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
•
Use cc group : Roger Clark 021310
Lot Sizclsq. ft): 'TING YVC)NNE
AiJp!icant: RUC+er Cl'
Al: 64 iU -
Apo/icantAddress: Phone: insurance:
PO Box34 S413) 584 -1170
LEEDSMA01053 ISSUED ON :3/17/2006 0:00:00
TO .PERFORMTHE FOLLOWING WORK: CONSTRUCT 12 X 20 SCREEN PORCH & 12 X
• 20 DECK
POST TIi: S CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
.s d J c4 rt(
Footings: Lova
Rough: R o u g h : house # Foundation:
Ff, ` Driveway Final:
Final: Final:
'�y 6 L. Rough Frame:
•
Gas: Fire Department Fireplace /Chimney: i
n:11. Insulation:
•
•
Final: Smoke: F :nal: OK G OA (ot4 tS
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF i'fS RULES AND REGUL
Certificate of Occupancy Signature_
FeeType: Date Paid: Amount:
Building 3/17/2006 0:00:00 $100.005163
212 Mai.; Street, Phone (413) 587-1240, ' ax: (413) 587 -1272
BoilOing Commissioner ari r;ny I tutllo