24A-080 SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ' !� < �/� `� � — "z,4- 7S-3
License Number
3 to C RC (,r- II tie i _ 1 0/ I el t
Address Expiration Date
c 12 Zc -
Signature Telephone
9. Rectistered Home Improvement Contractor: Not Applicable ❑
•
Company Name Registration Number
Address Expiration Date
Telephone -
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 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [D Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [0] Other [O]
Brief Des ption of P` l � f'
Proposed [^,
Work: c\.,2 S G v%Ck ` ?”9-(1,4 �. A LT -(e c - nPs-W- (- X441, L r
p -r—
Alteration of existing bedroom Yes No Adding new bedroom Yes V No - /
Attached Narrative Renovating unfinished basement Yes V No
Plans Attached Roll - Sheet
Ga. 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 5 �Q't. --L ti as Owner of the subject
property �7
hereby aut rize I `'V VJ EQ-4 Lk) A-LAtirot_
to act on y half, i all matters relative to work authorized by this building permit application.
Signatur of Owner Date
I, - RCA rNZ- 1/■J AA.AAirs tL. , 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.
Print Name
c20._..-t,...... lA ( L `ti (61
Signature of Owner /Agent 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 b.. filled in by
Building Depart, ent
Lot Size -
�
Frontage
CA
Setbacks Front 44)
i"
Side L: R: L:
Rear ° ,AtckiC , 1..)(• n.
Building Height \ ) n A,1`�'
Bldg. Square Footage % \"`'
Open Space Footage % v
(Lot area minus bldg & paved
parking)
# of Parking 1 aces
Fi .
olume & Location)
A. Has a Sp lal Permit /Variance /Finding ever been issued for /on the site?
NO DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO V DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , 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 Q NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, exc ation, 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.
w '
Department use only
1w City of Northampton status of Perri # :
r._$uilding Department Curb Cut/Oriveway Permit
'_ " `— 212 Main Street ' Availability
,, ' Room 100 Water/Well Availability
N0� 2 0 �- Northampton, MA 01060 Two Sets of Structural Plans
` phone 413 - .587 - 1 \240 Fax 413 - 587 - 1272 Piot/Site Plans
� _ e _. , C 0 Other Specify
ALPPLICA'TION'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
1 i Map Lot Unit
Zone Overlay District
EIm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1�O�wn of Record:
�" J CCPc 4- t' v -u k i S Q-124--At'
l3 �C-S t7i� -) N Uft-l� Z�I rte:
Name (P t Mailing Address:
4 , (..../(............ Telephone Current
Signatu e
2.2 Authorized Agent:
Name (Prin Current Mailing Address:
L___, S- — 1224
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building . (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
to ■'° , Construction from (6) —
3. Plumbing Z Building Permit Fee
4. Mechanical (HVAC) —
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) ' , A 1 t— � lj -� /3F? / /
. Check Number ( �g e)
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
L {
File # BP -2010 -0550
APPLICANT /CONTACT PERSON ROBERT WALKER
ADDRESS /PHONE 36 Service Center NORTHAMPTON (413) 584 -1224
PROPERTY LOCATION 104 JACKSON ST
MAP 24A PARCEL 080 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 13 f� 'PO;
Fee Paid j�' 7
Typeof Construction: REMODEL 2ND FLR BATH,ALTER STAIR HALL LAYOUT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 034783
3 sets of Plans / Plot Plan
THEFLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION PRESENTED:
Ap proved 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
Demolition Delay
It 20 d 0
Signature of Building 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.
104 JACKSON ST BP -2010 -0550
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A - 080 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- 2010 -0550
Project # JS- 2010- 000774
Est. Cost: $24350.00
Fee: $145.80 PERMISSION IS HEREBY GRANTED TO:
C onst. Class: Contractor: License:
Use Group: ROBERT WALKER 034783
Lot Size(sq. ft.): 19906.92 Owner: SERLIN DAVID M & REBECCA A
7 .ntncr LiP A(100 / 4nn/i rrnt: ROBFRT WAI_ KFR
AT: 104 JACKSON ST
Applicant Address: Phone: Insurance:
36 Service Center (413) 584 -1224 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON :11/20/2009 0 :00 :00
TO PERFORM THE FOLLOWING WORK: REMODEL 2ND FLR BATH,ALTER STAIR HALL
LAYOUT
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:
Roughl `[f ,., / /a/g/edat House # Foundation:
Driveway Final:
FinaL;j'v(f> d Final: // ��
;0 J t Rough Frameek IpZ // c? ...4
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation: 0
Final: Smoke: Final: OK of 12'5)0 Lel
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy
Signature: r s'
FeeType: Date Paid: Amount:
Building 11/20/2009 0:00:00 $145.80
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo