31B-093 (3) 5 ale 1-/4 son
- - - -
-
New-front Boar
ILL
Front Ele' vati-on'
scale 1/41 = 11 NAM 6u
S
4-ca lr2
Found-ation Flan
Scale: 114" = 1 ' ...011
5cidroorn room
1t {
{
j remove existing
i ceiling -and sheetrock
for now cailkv
a i �
f —remove carpet on ff
stairs and hallway, !
} refinish hardwood
treads and floor. ————--
New whole house fan.
Add exterior wall
venting
1
Second Floor Plan
Scale: 1/4
fnin
Both
remove carpet on
stairs and refinish
hardwood treads
add spring -
hinge to existing -
closet door
Front
/ Pof C}'1
6' length of --
clectric baseboard
tl r�_
J , - - '�__ -Yc•. s .—.. - ...ice �-� �: w� _
3
cer
First Floor Fi.an -
Driveway
House #10 t ~
INI
t c0
Existing.
House #17
line of
existing
r
/ -
6
3
property line 44'
t�
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work:
The debris will be transported by:
The debris will be received by:
Building permit number:
� rr
Name of Permit Applicant
y ��o
1
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ib1
Name (Business/Organizationadividual): -
I
Address:
City/State/Zip: ` E � Phone#:
Are you an employer? Check the appropriate box: Type of project(required):
. I am a general contractor and I
1.❑ 4
I am a employer with � 6. E]New construction
employees (full and/or part-time),hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
/, ship and have no employees These sub-contractors have g. EJ Demolition
working for me in any capacity. employees and have workers' E] Building addition
[No workers' comp.insurance comp.insurance.$
required.]
5. F� We area corporation and its 10.❑ 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#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners 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.Lie.#: 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 Gerd er thepains andpenalties ofperjury that the information provided above is,true and correct:
Si ature: Date: rY
Phone#
Official use only. Do not write in this area, to be completed by city or town official
City or Town: PermitUcense#
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:
f' f License Number
tic L4
Address t Expiration Date
Signature Telephone
9 Registered:Flbme-Improvemertt Contractor Not Applicable £
Company Name 'Registration Nu be r
1 � �n V
Address Expiration Date
-2,
Telephone Ll r(�7�� ?1, 2%6
SECTION 10-WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affida ' must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the b ' ing permit.
Signed Affidavit Attached Yes...... £ No...... £
11 �=H�o�rie (�lwner:�-ge�nptzan -
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 Icense,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 aH 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
or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs jet] Decks [[ Siding(0] Other[a
Brief Description of Proposed + ~- Q� ��t� _ Q`�' - ,� SW,rr�, -- (° r�
Work: �c
Alteration of existing��droom Yes No Adding new bedroom Yes / \No
Attached Narrative (�J� 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?
f/ i I
d. Proposed Square footage of new construction. Q! ensions
e. Number of stories?
f. Method of heating? \ 9 Fireplaces or Woo dstoves Number of each
g. Energy Conservation Complian 1,. \ I�Aasscheck Energy Compliance form attached?
h. Type of construction L. %
L Is construction within 100 ft.ofwetlands? 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
t,
�C�,�►� W ,a s Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signat of Owner
4 � 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 under the pains and penalties of perjury.
Pint Name
sign— at of owner/Agent Da
:A
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 '271
Side L: R: - k L.- R:
Rear
Building Height
Bldg.Square Footage T 0
10
C,
Open Space Footage
(Lot area minus bldg&paved
-kin )
#of Parking Spaces AID;
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO .0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO � DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES
IF YES, describe size, type and location: �` \
E. Will the construction activity disturb(clearing,grading ion,or filling)over I m it part of a co
Ton plan
that will disturb over I acre? YES 0 NO xcav
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.,
Department use only
City of Northampton Status of Permit:
uilding Department Curb CutfOriveway Permit
1 - 212 Main Street Sewer/Septic Availability
V�r 3
C-1 Room 100 Water/Well Availability
MA 01060 Two Sets of Structural Plans
Northampton,
hone 413-587-1240 Fax 413-
587-1272 Plot/Sde Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
� 0- Map Lot Unit
aZone Overlay District
Elm St District C8 District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
_ 4
nr �
Na Print) )I Current Mailing Address.�,tI?
g Z 1
Telephone
Signat4
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 ermit applicant
1. Building /! (a)Building Permit Fee
2. Electrical /b FF�� (b)Estimated Total Cost of
f�VIJ Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection vuv r '
6. Total=(1 +2+3+4+5) 5 Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
r 2
File#MP-2015-0032 ? J
APPLICANT/CONTACT PERSON GERRY SHATTUCK
ADDRESS/PHONE 25 S MAIN ST (413)237-9820 Q
PROPERTY LOCATION 17 BRIGHT AVE
MAP 31B PARCEL 093 001 ZONE URC(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
Typeof Construction: ZPA-ADD 2ND FLR BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure -
Building Plans Included:
Owner/Statement or License 058422
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved V 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: § ls� ` 9', 3 A — 4 � 7
Finding_ Special Permit Variance* otc_
Received&Recorded at Registry of Deeds Proof Enclosed
Other Pen-nits 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
Pennit from Elm Street Commission Permit DPW Storm Water Management
F
Signature of Building Of i ial 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 the Office of
Planning&Development for more information.