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City of Northampton
'11,:, liTet
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS p
g
212 Main Street • Municipal Building
,
`� Northampton, MA 01060
In accordance with Chapter 40, Section 54, Towns are required to issue a building permit for the new
construction, demolition, renovation, rehabilitation or other alteration of a building or structure. This is to
assure that the debris resulting the above will be disposed of in a properly licensed solid waste facility,
as defined by Section 150 (A) of Chapter 111.
The debris from construction work being performed at:
503 6 1 0
(Please print house number and street name)
Is to be disposed of at: 1
•
' 74)1t> ai-01(Please pint name and location off cility)0 DIIAPY}T-140 54--
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
hi
MOt 71—.
Signature of Permit pp scant or ner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
I
The Commonwealth of Massachusetts
Department of Industrial Accidents
�h f Office of Investigations
=11it=
_:. t._ � 600 Washington Street
e Boston, MA 02111
ul. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ►7)16 ,, 6--)Az V I/l./51I, )
Address: S )- . } 0 /1.1 g,e)
City/State/Zip: ,b i,,A <rl ii 0 In P one#: NO3 " S CC `1 ' -ik) D
Are you an employer?Check the appropriate box: Type of project(required):
1.n I am a employer with 4. El am a general contractor and I y ���
6. New construction
employees(full and/or part-time).* have hired the sub-contractors
Z.n I am a sole proprietor or partner-
listed on the attached sheet. I 7. n Remodeling -
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. _ workers' comp. insurance. 9. H Building addition
INN-worker- comp,-insurance„ - ._q 5. We are a corporation and its
T.. — 10.H Electrical repairs or additions
required.] officers have exercised their
(.. 3. I am a homeowner doing all work right of exemption per MGL 11.F1 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.n Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#I 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 their workers'comp.policy information.
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 c rtif nder the pains ii penalties of jury that the information provided above is true and correct.
Signature: GiIAA-)/) Date: 5) 1 51 13
Phone#: \\ \3 - 5(0-f . )P
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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
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 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 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, Stat- an• ocal Zoning L:w: a d State of Mas chusetts General Laws Annotated.
Homeowner Signature LA.A4 u■ta
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [] Addition X Replacement Windows Alteration(s) I I Roofing n
Or Doors El
Accessory Bldg. I I Demolition I 1 New Signs [D] Decks [1:7:), Siding [DI Other[DJ
Brief Description of Proposed S�c�n�c l� -�"l ► ��al - „/J L
Work: d�V �C �Xl..r
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
2 1 A . . , as Owner of the subject
property
)/Pfr '\fr y 1 ?c,7�2,UvS� ,
hereby author ze
to act on my half, in all matte r I tive to work au rized by this building permit application.
1 CIA 5) 15\ l3
Signa re of Owne•-! / Date
A A ' A , 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 undel the pains andne alties of perjury. 1
Print Name 1 r‘ ipt-W5tA )
,Q G1 )-§ \ )3
Signature of Owne gen �� ) Date
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Section 4. ZONING Alt 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: ,5 U R:
Rear.
`=A , yAt
Building Height
Bldg.Square Footage % li
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 0 DON'T KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW IR YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW O YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O Date Issued: g1 C31}\ 2..
C. Do any signs exist on the property? YES 0 NO Yi
NMI
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 k
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 0 NO
YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
�G�l� City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
� '��`3 212 Main Street Sewer/Septic Availability
1 f Room 100 Water/Well Availability
` 01`c s •-hampton, MA 01060 Two Sets of Structural Plans
ofe',"-0Q`ioN.y'•. e 413-587-1240 Fax 413-587-1272 Plot/Site 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:
T is section to be completed by fice
5o X13-, 1 t �, , Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
5.43 ON-.. 1 Der' iei- 0 Name(Print) Current Mailing Address: ` t
490, 04
I, A Al `� k/ _A i Telephone 3 ' �� l
Signs' re '
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. Building \�} 5 n OD (a)Building Permit Fee
bl
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) T Check Number //ry c(p —
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2013-1096
APPLICANT/CONTACT PERSON GLAZEWSKI HELEN S&MARY
ADDRESS/PHONE 503 MOUNT TOM RD NORTHAMPTON (413)584-4109()
PROPERTY LOCATION 503 MOUNT TOM RD
MAP 46 PARCEL 058 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out /! 3 9 Fee Paid I/6
Tvpeof Construction: CONSTRUCT 20 X 24 ELEVATED DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION ENTED:
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
Y"ermit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demoliti on Delay �.� e J(7IN s crz' F0,40 6.ava
Sir 7
Signa e 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.
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