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25C-021 (7) 116-0 1/2" 46-4 1 q'-2 1/2" --- ------ - - - -- - - - ----- ---30, - - - - - - - - -- --- - - - - - - - �Z. T 5-10" 1117 GARAGE 2,q,-5,x19'- BATH MUD ROOM 8'-5"x q, 9'-10"x q, I. ri -L ! / / 160 I J , I , � I � r I ry FAMILY C-4 18'-8"x 15-8" UP 45-10" UP 46-4 112" LIVING AREA 845 5LI ft -AT LAOIv PIPE 123.D'fJ- MON PIPE FIX,MD FOLM? t — — ACCESSWY B1ILDrW SETBACK LIhE VPrWWAY Pmt! Q 1.5 STWY NIF MAE 094 AVRTH STREET IL 1 1 1 SAR+1$f I i. I -- � M y 3.7'1/— 128.4'+J- DRI VEJVAY a ELISABETH D. MILLIAACS BOOK 9230 PAGE 39 PLAN BOOK 3 PAGE 16 a a H OF A''4c,, FAliLr � FEET 0 10 20 30 BUILDING 1 HOLly;BERG 3 4308 NOR THAMP7 The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations d I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Irtdividual); Zachary DePace Address:616 Alden Street City/State/Zip:Springfield, MA 01109 Phone#:413 244 7431 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. F-1 New construction 2.N I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp, insurance.: 9• Building addition required.] 5. ❑ 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.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box 41 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 pains and penalties of perjury that the information provided above is true and correct. Signature: `�` } Date: j -1 Phone#: 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#: SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signatud 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 exerftptlon fur"flon-icowilei S"-was extell�cd�0 11-1clude 0 Vviiei--GZL-u ------ and to allow such homeowner to engage an individual for hire who does not possess a license, yvo-tjkl-e�j as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. --.1 —F I-4 —;d- nn to there d s e d t o b-I, a o n e o r t,-:v o fa nn i• e 11 11-ing- c h or detacbed stn-;ctures accessory to such use and/or L--m structures.A verson who constructs more than one home in a two-veer period shall not be considered a homeowner. Such"homenw-ner"shall whmit to the Rnildincy Official nn a form 2rr(-.i-ntqhlP to the Ruildincy official.- thof qholj hp responSibl-fn-r all el-cl- --l' fni 7�=O; As actillaC-,!- o 7-. AI:7. completion of the work for which this permit is issued. A I So be M .1 1.-0, ( 4,,I,,*I;t\! tr, L-11ii. of Emolovers to d("h-,raqjt,er 15 3 you hire to perform work for you under this permit. The undej-si.g1-1,:-:UJ j lty foi k."Jiiipiiojl-c itji Lie VUC,;-1'" "I N tha-mint-n J 771-:- lort -..-ner SiffS natu-e SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing EJ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [u Siding [oj Other[�7l eM.au-e, Brief Description of Proposed S f Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet �e " 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family X Two Family Other b. Number of rooms in each family unit: '7 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 t �, Number of each g. Energy Conservation Compliance. Messcheck Energy Compliance form attached? h. Type of construction t 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? Y` Yes No . 1. Septic Tank City Sewer i' Private well City water Supply SECTION 7a-OWNER AUTHORIZATION -TO BE COMPLETED WHEN �,wru�r�e / nr _T CM --M w- F- n 1111 '!RIG PERMIT s as Owner of the subject property hereby authorize Q- ` <_ to act-on my behalf, in all,matters relative 4o work authorized by this building permit application. 2c i Signature of Owner Date if--`c: ,^- as Owner/Authorized and belief. Signed under the pains and penalties of perjury. Print Name Signature of ner/Agent Date Section 4. ZONING AR 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 Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking,Spaces (volume&Location) A. Has aSpeciai Permit/Variance/Finding ever been issued for/on the site? (9� �� NO DONTKNOYV \�� YES \~� |F YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? �� NO �� DONTKNOVV �� YES �� IF YES: enter Book Page and/or Document# B. D-oes he ca�n a bok bd n , n � � 67)� � NT KN�Yte \� O V 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? '— L ' �� isumed' ^� \ ' C. Do any signs exist on the property? YES \�/ NO \�� IF YES, describe size, type and location: /� ;� /`.'�{L/� �- D Are YES /—\ NO D. \�� IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, gradingexcavation, or0Uing)over 1 acre urisit part ofa common plan that will disturb over 1acre? YES ( ) NO (�) = �= IF YES,then a Northampton Storm Water Management Permit from the DPW is required. U ^� Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit i1 �J'.�L - i ` " 212 Main Street Sewer/Septic Availability ` I Room 100 Water/Well Availability Electric, F "ol`46rthampton, MA 01060 Two Sets of Structural Plans riorrc� p hone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATiON TO CONSTRUCT,ALTER, REPAIR, REwOVATE OR DEMC)LiSH A ONE OR TWO FAI%6LY DWELLING q 1=C-TICKI A _SITE Ins FC!c!!l;-kTION i 1.1 Property Address: This section to be completed by office Man Lot i init 17 r ! Zone Overlay District Elie St.District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 OwnersS of jRecord: M1a Name(Prim) Lp Current Mailing Add ;s: Telephone Signature 2.2 Authorized Agent: p Name(Print) Current Mailing Address. Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (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+0' +4+5) 3 C, , Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0035 APPLICANT/CONTACT PERSON DEPACE MARK&KAREN ADDRESS/PHONE 194 North Street NORTHAMPTON (413 267-9002 Q PROPERTY LOCATION 194 NORTH ST G� [ MAP 25C PARCEL 021 001 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 U{ dt t Fee Paid Typeof Construction: ATTACH GARAGE W/ADDITIONAL 18 X 20&CONSTRUCT 19 X 26 BATH, MUDROOM&FAMILY ROOM ADDITION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 84976 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved Additional permits required(see below) n PLANNING BOARD PERMIT REQUIRED UNDER:§ 3• ` 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 i elay 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. j 14 bs GJ7Q VgNIV ONIAII .9t, loe I/L t Z/L t-.9t, Ha0Y9C 990E —or HGOOC HactEn cin .OL L X..(R�q L AL/L 99L9 999E I b X.10 L-lb bj —j kooN cinH H-LIVG ti - — — — — — — — — —-- — — — — — — — — — — — ——— — -- — — — — — Z/t O-Rb IRON PIPE 1,23o0'+1- May PIPE FDtAtiD FOLM ACCESSORY BVILDIM SETBACK LIAE ZPrWNAY POACH T- o t.5 STORY M/F HOUSE o y: ►194 AVRTH STREET t } SAR W i -- 3.7'+1- 128.4't/— DRIYEMAY a ELISABETH D. MILLIAMS BWK 9230 PACE 39 ~' PLAN BOOK 3 PAGE 16 0 va i FEET 0 10 20 30 BUILDING 1 HOLAQSERG r� A No,34308 n NOR THA r7r-