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24D-249 (7)
Louis Hasbrouck Building Commissioner City of Northampton 212 Main Street Northampton, MA 01060 I request that you grant a modification to waive the requirement for construction control of the project at 76 Creent because the work is of a minor nature, will not affect health, accessibility, life and fire safety, or structural requirements and is impractical in that the cost of control construction is considerable when compared to the cost of the proposed work. Thank you for your consideration. Respectfully, 11 \ 3 °\ , c1 - N : \ P T 0 Version1.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes O No O SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, q +4 c „P—t i 4s Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 4 'Gay. N , 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. tC_- F Print Name //// Signature of Owner /Agent Da SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder . PM ')-it✓ . 96 4 Lf Z License Number 2 b rt-r� p, -t- 1 (22- 13 Address Expira n Dat G,-- -- --'_ (.1-4 2 t? Signature Telephone SECTION 13 - 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 0 No 0 Version1.7 Commercial Building Permit May 15, 2000 SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name (Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor t P CO /v✓ j - r i 2 U C 77 O \J Not Applicable ❑ Company Name: ERIC, ( E Responsible In Charge of nstruction i Address e (et)217 of 746 Signature Telephone Version1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building 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 ® DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW 0 YES O IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO co DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O 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 O NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Version1.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other J Brief Description Enter a brief description here. Of Proposed Work: `/ " \ ` ` ( y no J S C ` �'[ L ,�f`� -�2 vim. SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B 1 ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1 -1 ❑ 1-2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ®' R -3 ❑ 5A E S Storage ❑ S -1 ❑ S -2 ❑ 5B [ ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: C cs—..., <� — r 2_ Proposed Use Group: F. Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) 1 st 1 2nd 2 nd 3 3rd rd 4 4 Total Area (sf) Total Proposed New Construction (sf) Total Height (ft) Total Height ft 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public' Private ❑ Zone Outside Flood Zone Municipal On site disposal system Version!.7 Commercial Building Permit May 15, 2000 Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office C CS L �� Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: (i\ cvv... cA. e e A ++ &\ ^ lam a 0. Name (Print) Current Mailing Address: Signature Telephone 2.2 Authorized Aaent: Name (Print) (.. r (rl, 1-)"-\)1L-, Current S( Mailing Address: r 1 �^ 7 3"Z- ✓ / vs (p / Signature C/ { ` Telephone / `' / g `e`'.2 SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 6 0 © (a) Building Permit Fee 2. Electrical rj C-' a (b) Estimated Total Cost of Construction from (6) 3. Plumbing k.e3 Building Permit Fee 0 e3 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) t C3 , 00 Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date ' The Commonwealth of Massachusetts - --=1 Department of Industrial Accidents .....t .r a i 5 4 , Office of Investigations ! _w 1 -�:; 600 Washington Street �-- . • Boston, MA 02111 N, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Euz 1 C.- ? 4`f NE Address: 3 .7- ts . R 15 ? , -r Ci /State /Zia : Ma (2.1 A t\ PTb N/ Phone #: (4\3 Z" 41 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a er with employer 4. 0 I am a general contractor and I p Y 6. ❑ New construction employees (full and/or part - time).* have hired the sub - contractors 2.K I am a sole proprietor or partner- listed on the attached sheet. 7.0 Remodeling ship and have no employees These sub - contractors have 8. [] Demolition working for me in any capacity. employees and have workers' g Y P h 9. ❑ Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 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. ❑ Other comp. insurance required.] *My 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 pa" : , nd penalties of perjury that the information provided ab ve is true and correct. Signature: Date: 3/3 Phone #: ( /9 Z t V 9 7 -?' 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 #: StCTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder : C ( C. TA` G le License Num r 3 z Zu) R.-rs t (Z 15 Address Expiration Date (I- 13)2.115 421. b Signature Teleph e 9. Realstered Home Improvement Contractor: Not Applicable ❑ t co v TI 6 / 70 t6 , 1 . 7 CI Company Name Registration N tuber 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 1083.5.1. 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 A SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding [0] Other [ ] Brief Description of Proposed Work: K 1 TC 1-1 i✓ N '' E NikO 0 E. L Alteration of existing bedroom Yes / 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 1, 14- al{Vit L1k. a vt AI_ , as Owner of the subject property 0 hereby authorize - g1 L ? l / Nt to act on my behalf, in all matters relative to work authorized by this building permit application. Y.)---------) 1/ . - 74 13% Signature of Owner Date 1 E.R 7 L ?"0‹ L , 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. X 21 L. p.a. v'kJ Print Name /� � J3� Signature of Ownerl�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 be filled in by Building 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 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 Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ED DONT KNOW 0 YES 0 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 ® NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® 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 ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only A E City of Northampton Status of Permit: I _ ByIIdin Department 112 ain Street Curb Cut/Driveway Permit Sewer /Septic Availability Llibi __ 2 R Om 100 Water/Well Availability `1VbrtHiam ton, MA 01060 Two Sets of Structural Plans DEPT. OF 6' ,_ ©n J 413 -5�7- 240 Fax 413 - 587 -1272 Plot/Site Plans NORTHAMPTON Mq 07060 Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Proaerty Address: This section to be completed by office 1{c" L AS Lk uk 3- Map Lot Unit Wi - MA- out0U Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT g.1 Owner of Record: I". A r t"l ttoyuk_AJ A-. d.yWlk.iA q C-NeC. (, ii),,, tl _ , •0`" 1r � illsAi 04 - Name (Print) / Current Mailing Address: fi i GO LILk; ?■---- Tlephone Signature 2.2 Authorized Agent: is is p/ (t) 32 I60R"CS -\r F � Name (Print) Current Mailing Address: l - -- \ j/l- - - ( 13 'ZI g 42 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building + S 06 O (a) Building Permit Fee 2. Electrical 4100G (b) of Construction from (6) 3. Plumbing ft 1 o00 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) $4O Check Number 073 3 11 (5 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0683 APPLICANT /CONTACT PERSON ERIC PAYNE ADDRESS /PHONE 32 BURTS PIT RD NORTHAMPTON (413) 218 -4276 () PROPERTY LOCATION 76 CRESCENT ST - UNIT #2 MAP 24D PARCEL 249 001 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 0 7v 2 3 01 Typeof Construction: REMODEL KITCHEN New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 086442 3 sets of Plans / Plot Plan THE F OWING 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 Peimiit 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 7/13 i nature of Building Official Date Signature g 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. 76 CRESCENT ST - UNIT #2 BP-2013-0683 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 249 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- 2013 -0683 Project # JS- 2013- 001131 Est. Cost: $10000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ERIC PAYNE 086442 Lot Size(sq. ft.): Owner: FLANNERY MAUREEN A Zoning: URC(100)/ Applicant: ERIC PAYNE AT: 76 CRESCENT ST - UNIT #2 Applicant Address: Phone: Insurance: 32 BURTS PIT RD (413) 218 -4276 () NORTHAM PTONMA01060 ISSUED ON:1/7/2013 0:00:00 TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN 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 1/7/2013 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner