31B-303 I
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supe isor: Not Applicable ❑
Name of License Holder : - '1 &it� 2._ "\ k A,
License Number
_ ?\ crt-QiN R� 9
Address hi
Expiration Date
_. ; 31 /zoi
Sig ' T`lephone
.
9. atered.H eimprovemebf tractor .,,.., , .. ,. ;4,4 .�.. _, Not Applicable ❑
Company Name ` ! .V WM
Registration
I Regist i Number
Add s 18 3
Expiration Date
r .e.2,4 C . 7 Telephone r A 0
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 ❑
1L , ... ' ili • v.e '. ,241nu 'o... 6! a E #
The _ current_ exemption for ` homeo_wn. ss" was_extended to include Owner - occu ied Dwellin s of one (1) or two(2) families
and to allow such homeowner to engage ..• individual for hire who doe i possess license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition • tion 108.3.5.1.
Definition of Homeowner: Person (s) who o parcel of lan • on which he /she resides or intends to reside, on which there
is, ui is iiitciided to be, a one or two family dwellin_ attaoh . or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one • , .e in a two - year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Offic•. , • • a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under e buildi • permit.
As acting Construction Supervisor your pres- ce on the job si ; will be required from time to time, during and upon
completion of the work for which this pe • is issued.
Also be advised that with reference'to • .pter 152 (Workers' Compe •tion) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting i • D eath) of the Massachusetts Gene , 1 Laws Annotated, you may be liable for person(s)
you hire to perform work for you u er this permit.
The undersigned "homeowner" rtifies and assumes responsibility for compli..• ce with the State Building Code, City of
t o ampton •r• mances, au • li . ■ r a - -r-al-Laws-Annotated.
Homeowner Signature
` y .
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding [D] Other
Brief Description of 1 Propose - • -
Work: Y 1 h *V+ 1 i 1 (.. I ft) Z } .t"1 1 i • 1 ,..s
Alteration of existing bedroom Yes No Adding new bedroom 'Yes No
Attached Narrative Renovating unfinished baseme t Yes No
Plans Attached Roll - Sheet
4:' If Neilithotiii ilott incWdorrtplete:t ie,fuliaignq:
a. Use of building : One Fa I iI • Family a, Other
w
b. Number of ro each :mil . it: t. • ' mber of B_ roo. s vlro /I:
c. Is there a arage attached? Vt b
-
d. Proposed Square footage of new construction. Dimensions
i
e. Number of stones?
- -
/
f. Method of heating? ireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. / Mas eck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 • . •f wetlands? Yes No. Is constru ' within 100 yr. floodplain Yes No
j. Depth of basement • 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
1 A r 4.&_ kAA.I I bel q , as Owner of the subject
property ✓ , / ,
hereby authorize Vl V i
to act on my behalf, in 1\,F-Irk.°)VV1 matt erelativ �t rk a ized by th s building permit application.
")( ;a..J.- - je-4.-4-- 1 ,..-- - (Vs/ 0 9
ignat re of Owner Date
1, gOV7VLA.. JC.v.11 ive`.c , as Owner /Authorized
Agent hereby declare that the stateme and inforrnation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
.1)/ (4,--- `CA- C Lk, erj
P 'nt Na :.�
_ ./�°� dr if -
Signature of Owner /Agent v Date
f
O
,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Info9ation
Existing Proposed Required by Zo i ng
This column tole filled in by
Building Department
Lot Si
Frontage
Setbacks Front
Side L _,.. __...,.2 L.._. .. ___ ,__.___
Rear
Building Height
Bldg. Square Footage % 7
Open Space Footage %
(Lot area minus bldg & paved _. , -
parking)
# of Parking Sp. - -s _ ,
Fill: 1 q
1 ( vo e & Location) ----- �... — ,
—
A. Has' S ecial Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES 0
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 Book ' € Page? and /or Document # __ .._ �
B. Does the site contain a brook, body of water or wetlands? NO/ DONT 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:
f
C. Do any signs exist on the preperty? YES 0 NO cit
IF YES, describe size, type and location: ,
- __`V — - D.' - Are`IDt"Pier`e`an ro ose• c an es to or a. •1 ions o si ns inteniedfi the property ? YES f NO S
YP P g gP P Y
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, gradi - , excavation, 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.
City of Northampton
Building Department c J Apl,a0,
212 Main Street
Room 100 ;,•
n ,G Northampton, MA 01060
‘ve
1 • ' phone 413-587- 240 Fax 413-587-1272 7 r0 e 7 4'1!
..40,, 40..dV,0=0:," =
,S wtIV Int,r
APPLICATION TiQCONBTRUtt, 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
t7 M etit4J4 "di St • Map Lot Unit
AlVeliA1 17711- C /19(e
Zone Overlay District
EIm St District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
JX01-11/ k- --PPA c:Ivatlet noltr Poileib4osipirx
Name Print) Current Mailing Address: (1 5 )..e/9-0,2 7
Telephone
Signature
2.2 Authorized Anent:
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 7 ° (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 = (1 +2+3+ 4 + 5) Check Number _117.6-v
This Section FO1Offiiiil Uii Only -
Date
Building Permit Number Issued:
Signature:
Building Commissioner/Irtspector •of Buildings - Date
f .
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. 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 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 • spected.
If the homeowne hires o r trades to perform work (electrical, plumbing & gas) the
homeowner will a responsib to make sure that the trades hired secure thsk proper
------- - - -- -- its -in- conjunction -to thebu, • • • • - •II' issued,_. and ._ that they get tk it required
inspections. Failure of the indivi. ► . trades to secure the permits an• nspections as
required can DELAY the project unt such time as the proper pe its and inspections are
made
I, understand the above.
(Home owner /resident's signature requ • g exemption)
I will call to schedule all required building i s .. e ' • ns necessary for the building permit
issued to me.
e
Address of work
location
N .,
/ • 1
The Commonwealth of Massachusetts
_,,, Department of Industrial Accidents
=i301.7...-7. f^i' Office of Investigations •
600 Washington Street
,=1:1:1..-= � Boston, MA 02111
www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): \ \ \ WM \ e )7 a �A S
Address: Ci 4 jf /�, 6 \jC
-
City /State/Zip: N Phone . #: ^ Z°3
Are you an employer? Check the appropriat box: Type of project (required): /
1.0 I am a employer with 4. 0 I am a general contractor and I 6. n New constriction
employees (full and/or part- time).* have hired the sub- contractors
2. 07: I am a sole proprietor or partner -
listed on the attached sheet. 7. 0 Remodeling
s . ?rd. have no e. 1oy ees These sub - contractors have. 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' comp. insurance - comp- _insurance-
�
re uired. 5. 0 We are a corporation and its 10,0 Electrical repairs or additions
required.]
3. I am a- iomeo- waer--d ing -all-work ..__ .__ - -- cersave J xercised eir - -�.. f Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 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. m1114
Iam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
ormation.
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, - day against *lie violator. to advised' that a copy of this statement may be forwarded to the Offi ;e of
Investiga1i I of th • IA for ins • - ■ veraze verification
I do hereb ∎1 nib, u � � ,.. • , , r i _ aides ofper? Y that the information provided _above_ittrue- and_correct__
Siu..ture: r / ;k.( .k = �'�al2 •ate• 1 • _o ff •
Phone #:
— Official Official use only. Do not write in this toto: be completed b c' or mown o ia1
� y � - ffci
City or Town: Permit/License #__
Issuing Authority (circle one):
f. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
22 EDWARDS SQ BP- 2009 -0320
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 303 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
cute ma x- BUILDING PERMIT
Fermi ff BP- 2009 -0320
Project tt JS- 2009 - 000433
Est. Cost: $22160.00
Fee: $132.60 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GARY J CHAGNON 060175
Lou Siie(sq. tt.): 3484.80 Owner: KULLBERG MATTHEW & DONNA
Zoning: URC(100)/ Applicant: GARY J CHAGNON
AT: 22 EDWARDS SQ
Applicant Address: Phone: Insurance:
91 STOCKBRIDGE ST (413) 259 - 6785 WC
HADLEYMA01035 ISSUED ON:10/15/2008 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL ATTIC SPACE TO CREATE 2
BEDROOMS W /NEW STAIRCASE
POST THIS CARD SO IT IS VISIBL R E S
Inspector of Plumbing Inspector of Wiri 1 '.W. \ Building Inspe or
Underground: Service: Meter:
0o s:
Rough: Rough: House • / Fou tion:
Dr' e r .1:
Final: Final:
' • i gh Frame:
1
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 10/15/2008 0:00:00 $132.60
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -0492
APPLICANT /CONTACT PERSON NATHANIEL DAVIS
ADDRESS /PHONE 18 PLEASANT GREEN (WEST) EASTHAMPTON (413) 529 -0608
PROPERTY LOCATION 22 EDWARDS SQ
MAP 31B PARCEL 303 001 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
Type. I ction: REMODEL ATTIC SPACE TO CREATE 2 BEDROOMS W/NEW STAIRCASE sz ;r P`
.,,
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 084975
3 sets of Plans / Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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
Demolition Delay
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.
22 EDWARDS SQ BP -2010 -0492
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 303 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catep?nrv: renovation BUILDING PERMIT
Permit # BP- 2010 -0492
Project # JS- 2009 - 000433
Est. Cost: $4400.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: NATHANIEL DAVIS 084975
Lot Sze(sq. ft.): 3484.80 Owner: KULLBERG MATTHEW & DONNA
"Lomita: U RC(100)/ Applicant: NATHANIEL DAVIS
AT: 22 EDWARDS SCE
Applicant Address: d'hone: Insurance:
18 PLEASANT GREEN (WEST) (413) 529 -0608
EASTHAMPTONMA01027 ISSUED ON :11/5/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL ATTIC SPACE TO CREATE 2
BEDROOMS W /NEW STAIRCASE - FINISH ONLY
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: OK t / - 24 i c ` v
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANN OF ITS RULES AND REGULATIONS.
Certificate of Occupancy( /S ignature:
FeeType: Date Paid: Amount:
Building 11/5/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Connllissioner - Anthony Patillo