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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable El
Name of License Holder: I G 2 k- `��" J �2 1 V1)
�j �* / License Number?
am' �C� -�i `-{.N t�'l,�('�— 1�t �L t 1 t` (L 1 1`U' 7'c'C
Address Expiration Date
Signature Telephone
S.Registered Home Improvement Contractor Not Applicable ❑
T� (=e ICA I.7 1-(:)ito
Company Name Registration Number
6'�1 1A-1 'acs {,q.'
Address
,�, Expiration Date
1 :4 `N� \+� —Y �N eA Telephone 2 2 a
—
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 Officials 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 ❑ Addition ❑ Replacement Windows Alteration(s) Roofing n
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding[0] Other[0]
Brief Description of Proposed �,n
Work: ('pry V e r-i— 2 I.'" C4 f1 13 irbe l,t.-.. -to tom.11. ;L A-
v' Y
Alteration of existing bedroom es No Adding new bedroom Yes 1/1N/o
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - he
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? CI
d. Proposed Square footage of new construction. \'Dimensions
e. Number of stories? <
f. Method of heating? Fir-• -ces 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 wetl--.s? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cell. oor below finished grade
k. Will building conf•' to the Building and Zoning regulations? Yes No.
I. Septic T. City Sewer Private well City water Supply
S CTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 7(;/r9 7"1P-i--- ,-C-,-J C1 , as Owner of the subject
property Q ., //K�
hereby authorize / '0�P ( C f ]Y '7
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
\-2C) a \NAP'k 'ce 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 underjepains and penalties of perjury.
Print Name
' .(.'rtA--■ -- Vk-iaL_______ k' CI ( i
Signature of Owner/Agent Date
y
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by oning
This column °•be filled in by
Build'''. Department
Lot Size
Frontage
Setbacks Front
Side L: R:- \ L: R:
Rear
Building Height
Bldg. Square Footage
"`i
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spac;
Fill:
(volui•-&Location)
A. Has a Sp cial Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW Q 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 Page, and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO g# DONT KNOW Q 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 Q 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,exc ation, 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.
r
Department use only
__ ___. __ Ci of Northampton Status of Permit:
RECEIVED
Bu !ding Department Curb uDrl++eway Perrrllt
12 Main Street SewerlSepttc Avallabtlity
1 l Room 100 WaterANell Ayailabtlity,
Nort ampton, MA 01060
Two Sets of Structural Plana
DEPT.of BUILDINC�ndrecrsi[71q 3-5 7-1240 Fax 413-587-1272 Ptot/Site'Plans,
NORTHAMPTON,MA 01060
mar peoifY.
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
Z1, \\C \L 7l N ':,--.-t-, Map Lot Unit
'v(-){ } fkt\A-- 7-U N `/ "t -'�v.. Zone Overlay District
u u 0 tl Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
f31(ii 'ai,e f ge(7,'n {S c,9 , /-/arn 9r/to it 1vc.-f ,/161)-,1i4jrf: ,,,,
Name(Print)] Current%airing A cress:
_ Telephone
Sgnature
2.2 Authorized Agent:
ut``o'?E z c L i/'_ 3G CT-{z-1•11-C4 C t ''‘.`&- f l/"n 1J
MA
Name(P t) 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 r ()L) (a)Building Permit Fee
2. Electrical (� (b)Estimated Total Cost of
—7 Ulf Construction from(6)
3. Plumbing s‘c`_ Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection �� I�
6. Total =(1 +2+3+4+5) \, L\I i.bO Check Number /5 W ��
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2013-0947
APPLICANT/CONTACT PERSON ROBERT WALKER
ADDRESS/PHONE 36 Service Center NORTHAMPTON (413)584-1224
PROPERTY LOCATION 25 HAMPDEN ST
MAP 38D PARCEL 018 001 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 `� (1/
Fee Paid /
Typeof Construction: CONVERT 2ND FLR BEDROOM TO FULL BATH
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
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO N PRESENTED:
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
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.
25 HAMPDEN ST BP-2013-0947
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38D-018 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-2013-0947
Project# JS-2013-001585
Est. Cost: $14100.00
Fee: $84.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ROBERT WALKER 034783
Lot Size(sq. ft.): 1 1020.68 Owner: ROUNDS CALEB M&MARGARET B
Zoning:URB(100)/ Applicant: ROBERT WALKER
AT: 25 HAMPDEN ST
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:4/23/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:CONVERT 2ND FLR BEDROOM TO FULL BATH
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 4/23/2013 0:00:00 $84.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner