24A-223 (2) tj
CA,
9bi
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: /!7 �7i (n lec"2 f �� (�l CS" 7
License Number
Address Expiration D
el—
Signature /;` Telephone
l/
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 ex( 10 "homeowners"was extended to include Owner-occu ied Dwellings of one(1) or two(2)families
and to allow such homeown<to engage an individual for hire who does not possess a ee ise.provided that the owner acts
as supervisor.CMR 780 Sixth--Edition Section 108.3.5.1.
Definition of Homeowner:Person(s) own a parcel of land on wh' a/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dw ,attached or ched structures accessory to such use and/or farm
structures.A erson who constructs more than one m a two- ear period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Offi ' ,o form acceptable to the Building Official,that he/she shall be
responsible for all such work performed and a buildin rmit.
As acting Construction Supervisor your sence on the job site wi a required from time to time,during and upon
completion of the work for which th' ermit is issued.
Also be advised that with refer a to Chapter 152(Workers'Compensation) Chapter 153(Liability of Employers to
Employees for injuries n suiting in Death)of the Massachusetts General Laws otated,you may be liable for person(s)
you hire to perform r for you under this permit.
The undersigne orn owner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampto rdinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Hom wner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs (0] Decks [Q Siding[0] Other[o]
Brief Description of Proposed >
Work: JJl
Alteration of existing bedroom Yes l s' No Adding new bedroom Yes L.' No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existina 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
I, /•// / C�IG C'L C04 as Owner of the subject
property J
hereby authorize
to act on my be alf, in all matters relative to work authorized by this building permit applicatio .
Signature of Owner Date
as OgMr/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.
Z:'� / � a j��l'� �►
Print Name
Sign re of Owner/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 Q DONT KNOW O YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW Q YES Q
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 O NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q
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 Q NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
\ C of Northampton Status of Permit:
ing Department Curb Cut/Driveway Permit
5VI\60 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,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
A � � Map Lot Unit
d Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Loa.e
Name(Print) �— Current Mfiiling Address:
Telephone
Signature
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 rmit applicant
1. Building le jo. 0 U (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number 6
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-1203
APPLICANT/CONTACT PERSON QUINLAN BUILDERS
ADDRESS/PHONE 9 HILLSIDE DR HADLEY (413)549-5474 Q
PROPERTY LOCATION 27 TERRACE LN
MAP 24A PARCEL 223 001 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
Tyneof Construction: CONSTRUCT 4 X 4 DECK TO POOL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 011289
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION 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
Dela
S ture of Buil mg Of cia 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.
27 TERRACE LN BP-2014-1203
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A-223 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Deck BUILDING PERMIT
Permit# BP-2014-1203
Project# JS-2014-001871
Est.Cost: $1800.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: QUINLAN BUILDERS 011289
Lot Size(sa.ft.): 18338.76 Owner: O'SHEPA MICHAEL&LAURIE
Zoning_URB(100)/ Applicant: QUINLAN BUILDERS
AT. 27 TERRACE LN
Applicant Address: Phone: Insurance:
9 HILLSIDE DR (413) 549-5474 ()
HADLEYMA01035 ISSUED ON.511612014 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 4 X 4 DECK TO POOL
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 si nature:
FeeType• Date Paid: Amount:
Building 5/16/2014 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner