30A-081 SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supprvisor: A� /� P / ' U�"`,, Not Ap ❑
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Name of License Holder : ' Q +A ' ,(�iobe �Qom( / /) 1''o 1 ' W I (3 9 0
/ License Number
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Address Expiration D te
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Signature Al f r / Telephone
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H ' / tn• rov ki Not Applicable ❑
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Company Name Registration Number
--; 6 Pt) eThO 114,( Co Oro ft.?
Address , Expiration Date
Py� h
Telephone J0, O v U /
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SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG.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. - RQme ; 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 p 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 Offic ond a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the bu p ermit.
As acting Construction Supervisor your presence on t jo si te 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 ❑ Addition ❑ Replacement Windows Alteration(s) lg Roofing ❑
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [0] Other [0]
Brief Description of Proposed / ei, C,e, /1-� , i0 j , [ ow �/1^�A/ o 1 145.1-kw,
I'NV
Work: �/�V� GVaI/ [ D "h�1�'r ��G��
Alteration of existing bedroom Yes X No Adding new bedroom Yes No " — ' G �
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa. 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. B ensions
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. • , etlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement • cellar floor below finished grade
k. Will buildi►: conform to the Building and Zoning regulations? Yes No .
I. - • is Tank City Sewer Private well City water Supply
/ SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
• A P "I /T, Aj , as Owner of the subject
property
( A l � ""(L, 0n �/ �,Q
hereby authorize (V F' ' ¶ . "i �G �2
to act on my behalf, in all matters relative to wo horized by this building permit application.
Signature of Owner Date
(, 1 , Is ./ i (4> f : , as Owner . uthorized
Wan ereby declare that the statements and information on the foregoing application are true and accurate, to the best o y no edge
and be ief.
Signed under the pains and penalties of perjury. pp
/ MO i r (.0 e-,'
Print Name /// / //
Signature o Owner /Agent Date
-PrIA- ketil. Woef- 'fb P( Ntt liii) tIci siri_ „ _6
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 . • .y
Building Department
Lot Size _._ _..
Frontage i __ _ _ ___
Setbacks Front i j
Side L.- 4 R _._..._ __ L: 1-7
Rear , _ _-
Building Height r ---- 1
Bldg. Square Footage _ _" : % E1 _ r ____ ,
Open Space Footage _ % r ----- - - - ---
(Lot area minus bldg & paved _ L,_ ll
parking)
# of Parking Sp.. s - -_, i____ ___s
Fill:
ume &Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW N P; YES 0
IF YES, date issued:; i
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 #L i
B. Does the site contain a brook, body of water or wetlands? NO (2) DONT KNOW 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 0 NO i1►�
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 38(
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading ex - ation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO "4
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
mk, '
< < peer, lit,�� 1�` ��
L.........._________ j.............____Isli:
City of Northampton Staf aaf p'
1 5
uilding Departments
3 212 Main Street Sewer/Septic IityX ' 1 ,
Room 100 tF a �"
DEPT. NORTHA ON MAO 0760 NS rthampton, MA 01060 T Sets of � PIans
phone 413- 587 -1240 Fax 413- 587 -1272 Plo Sit ,s
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed lay office
1.1 Property Address:
I 6 /.j- '�,^ r ,� e - A Qp . Map Lot Unit
cs ' V , ' M tr o ( L D -- Zone Overlay D
11 -6 ti [strict
" Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
A is-lLA"ii‘l' 110 #1ill?f mes,v PI), 'Go l`i' M-
Name (Print Current Mailin l Addrer: /^ �J + n p�
Telephone
Signature
2.2 Authorized Agent:
(U ' ' '• a / 4./ ` Vb - ' i/ ' A t P. LUG'I' 4B RA-Tug' Sr ND k) 4 ? el e `-°N, MA'
Name (Print)' / Current Mailing Address:
Signature Telephone /
SEC • N 3 - ESTIMATED CONSTRUCTION COSTS 4 f it / x * 41 /0 0 0 . — = 74 it'
Ite ® Estimated Cost ( to be Official Use Only
completed by permit applicant
1. Building 11 2-3 `) r (a) ; Building Permit Fee
/
2. Electrical ' ! •)-4 yrt, i • (b) Estimated Total Cost of
( • Construction from (6)
3. Plumbing t q (if �
. . Building Permit Fee
4. Mechanical (HVAC) 7
5. Fire Protection C - )�
6. Total = (1 + 2 + 3 + 4 + 5) i `� 3, �5- . Check Number ' 5
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0832
APPLICANT /CONTACT PERSON WRIGHT BUILDERS
ADDRESS/PHONE 48 Bates St NORTHAMPTON (413) 586 -8287 (116)
PROPERTY LOCATION 16 HIGH MEADOW RD
MAP 30A PARCEL 081 001 ZONE SR(101) /WSP(23)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 40 r 2/ 1/
Fee Paid �/
Tvpeof Construction: ADD BASEMENT BATHROOM & REMODEL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 16370
3 sets of Plans / Plot Plan
THE FO WING A TION 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 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
'fstnDe •y
3-/5
Signature of : ilding • 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.
16 HIGH MEADOW RD BP- 2013 -0832
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30A - 081 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- 2013 -0832
Project # JS- 2013- 001431
Est. Cost: $43205.00
Fee: $264.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WRIGHT BUILDERS 16370
Lot Size(sq. ft.): 350658.00 Owner: AGRAWAL JANA
Zoning: SR(101)/WSP(23)/ Applicant: WRIGHT BUILDERS
AT: 16 HIGH MEADOW RD
Applicant Address: Phone: Insurance:
48 Bates St (413) 586 - 8287 (116) Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:3/18/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD BASEMENT BATHROOM & REMODEL
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 3/18/2013 0:00:00 $264.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner