17D-038 Section 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
Frontage _ .__ .__ _._ "..__._ __ . "_._ .._.__.____.__ ._.) _.__._,_... ------
Setbacks Front , _
Side L. R: - = =i L: �. R. I
Rear Rea.....1 ^.
Building Height E-1 .____
Bldg. Square Footage . r 1 % I ` "i
Open Space Footage %
(Lot area minus bldg & paved L___ j _ ... "-"
parking)
# of Parking Spaces.
Fill: S : 1
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
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 I - Paged and /or Document #1
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0
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 Q NO 0
IF YES, describe size, type and location ; i
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q 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 ® NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department, use only
City of Northampton Status of Permit:
Building Department Curb Cut/Dnveway Permit
212 Main Street Sewer /Septic Availability
Room 100 VVater/i/Velf Availability<,.._....
Northampton, MA 01060 Two of Structural Pans
phone 413 -587 -1240 Fax 413 - 587 -1272 Plot/Stte`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
2'1 1141.1- ST Map Lot Unit
FLO me,' Us '' /O 6.2 Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: �y
L �� 1 *te e h � S {. a� h; ' �l:x Cn cP �►tif0
Nam r Current Maili Address i tip q
� r � I i� Telephone ��J °' 3
nature
2.2 Authorized Agent:
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, '� �� L 1 (a) Building Permit Fee
lam 3 5 V
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) 3 5 1` Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) �� G f � I
M ar �� License Number Expiration Date
Name of CSL- Holder L ist CSL Type (see below) /fSU ) 0r' 6c—
15n O1 t.Soun+ StR k Z� � 1zi r,
Address Ale Description
`"b' U Unrestricted (up to 35,000 Cu. Ft.)
ff �'� R Restricted 1 &2 Family Dwelling
Sig ature M Masonry Only
' f3 _
SO�� O O� RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home mprovement Contractor (HIC)
Oozy )#1 VV1 e- P ei fr, 44, c A 4-
HIC Company Name or HIC Registrant Name Registration Number
(f3 D F ie ti S0-41 - Strto r �4t 5 thr�n /�
Address
'e„( ° { t 6193) .S 9 0 aoc x piration Date
Signature Telephone
SECTION 6: 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 ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OW, ER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, � �� 1 ) � r1 c■I , as Owner of the subject property hereby
authorize 3 Z ■ - 1 to act on my behalf, in all matters
relative to work aut orized by this building permit application.
Signature of Owner Date _
SECTION 7b: 0 ' NER OR AUTHORIZED AGENT DECLARATION
I, • 4 111...._ , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
beh f (L ( 1, 7 ci �1
Print Name,/ "
Sig ature of Owner . - uthorized Agent Date
(Signed under the pains and penalties • perjury)
NOTES:
1. An Owner who obtains a "building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively.
2. When substantial work is planned, provide the information below:
Total floors area (Sq. Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area (Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost "K S
The Commonwealth of Massachusetts
Department of Industrial Accidents
.tr --..
i; R- ��� 1 Office of Investigations
i =-. '_ ,�.� 600 Washington Street
ti� • , • ,6„•,.) Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Con tractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business %Organization /'Individual): eoz., eL per r(1'1 Qr P C LAX__
e
Address: / 'j 0 A €CLSC�.(1+ cS1 -e u Sb k 4
Ciry /State /ZipSW Nn a - ma V (3 . "'Phone #: 6t3 S2 • C`3 _0C),
Are you an employer? Check the . ppropriate box: }
Type of project (required):
1. Ur 1 am a employer with 6 4. ❑ I am a general contractor and I
6. ❑New construction
employees (full and/or part-time).* have hired the sub - contractors
listed on the attached sheet. 7. ❑ Remodeling
2. 11] T am a sole proprietor or partner-
ship and have no employees These sub - contractors have g. n Demolition
working for me in any capacity. employees and have workers'
working } p 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10. ❑ 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.] ' c. 152, § 1(4), and we have no
employees. [No workers' 13N'Other`Ji1�(7
comp. insurance required.]
Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
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.
_ w
Insurance Company Name: a S le ,, i n:ur in � _6 _! 1 C • ` ' , a 1 n
Policy 4 or Self `4t
Self-ins lLic. #: & _ D – j — 01 " ( '� 1 Expiration Date: i j l • �
Z ! 1 Z SCI
x f ( 4 1 U ) 0 k 3ob Site Address: t y/ ST � 11 rt j lP\ t'i City/State /Zip: d.) (NCR__ 41 ‘ C"
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 51,500.00 and /or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 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 cgrify under � the pains nd penalties of per' that the information provided above r iistrue and correct.
Signature: ,k/ ckA. _ a Date: �9 /2S /a
Phone #: oti :3) s ' o,, on
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 #:
-- The Commonwealth of Massachusetts — 1 FOR
Board of Building Regulations and Standards
1 V Massachusetts State Building Code, 780 CMR MUNICIPALITY.
USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2 011
One or Two - Family Dwelling
This Section, For Official Use Only
Budding Permit Number: Date Applied:
Building' Official (Print 1' Name) S _
Signature D . . .
Building
SFCflO1 11 SiT.E
1.1 Property Add } 1.2 Assessors Numb k
`"j )-) '39., , -PIA c r�( ((
- 1.1a Is this an accepted street? yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area (sq fi) Frontage (fi)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (IVLG.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Z,one: ___ Outside Flood Zone?
Public 0 Privare 0 Mtmicipal El On site disposal system 0
Check if yes0
2.1 Owner of Reco
N e 1 (P n nt) C � City, tate, ZIP )
Yl
No No_ and _�.. Telephone Rmail Address
S`ECT,IOi 3 DESEI W TION O .'`I O ORK . a 11 ai 1h a. i p .
A
New Construction ❑ Existing Building ❑ Owner- Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition
Demolition ❑ Accessory Bldg. ❑ Number of Units__ Other 0 Specify:
Brief Description of Proposed Woi k P' 54 a\ 1, L 4r•) ors > a, S Q v 1 r\15
Ak_K__ � 'T 4,e - •\ 1 )
SECTION 4 E CONSTRUCTION COSTS:
Estimated Costs:
Item Officials Use Only
_ (Labor and Materials} ,
1. Building $ `1 Building Permit Fee : $ IndiCatft how fee is deters ined:
2. Electrical -- ____ $ 0 Standard City/ToWn'Application Fee
_.-- -__ _._ ___.+.._._. O Total Project Cost (Item 6) x Multiplier __ x
3. Plumbing $ Z Other Fees: $
^
4. Mechanical (I1VAC) $ List: --
5. lvfechanicai (Fire -
Suppression) I Total All Fees: $
Check No. Check Amount: _-_ Cash Amount:__
' 6. Total Project Cost: 1 $ 3 s ) ❑ Paid in Full ❑ Outstanding Balance Due: —
File # BP- 2013 -0514
APPLICANT /CONTACT PERSON MARK LANTZ
ADDRESS/PHONE 180 PLEASANT ST EASTHAMPTON (413) 320 -7611
PROPERTY LOCATION 24 HIGH ST
MAP 17D PARCEL 038 001 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
Fee Paid 10 6"
Typeof Construction: INSULATE & AIR SEAL ATTIC
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 102169
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO PRESENTED:
A pproved 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
0 oliien' =.y
/�
.-- ,
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.
24 HIGH ST BP- 2013 -0514
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D - 038 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2013 -0514
Project # JS- 2013- 000821
Est. Cost: $3500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sq. ft.): 5749.92 Owner: FENNESSEY WILLIAM J
Zoning: URB(100)/ Applicant: MARK LANTZ
AT: 24 HIGH ST
Applicant Address: Phone: Insurance:
180 PLEASANT ST (413) 320 -7611 WC
EASTHAM PTON MA01027 ISSUED ON:11/1/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE & AIR SEAL ATTIC
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 11/1/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner