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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: C,--^,7- ZTti �.
The debris will be received by: �-
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: �-1
License Number
\M A . C 4.4vNA- k o \0 6c°
Address Expiration Date
Signat a Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
-'. 7 A• �1 a--R-.I-L ti.v..�..r W eN r _l aJ- t-7-1 0O % 1
Company N meP Reegistration Number y a.lk
Address Expiration Date
Telephone L.*-L yl—cx71°l
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,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
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SECTION 5-_DESCRlPTJ0N f?f._PRtJPtt f 8�4141 iF2#S cs erk Pt_,ay A"sc 3ej
_....
New House Addition Replacement Windows Alteration(sl Rocifing
Or Doors
1 At:r_essM Bldg Demolition New Signs ti ) Deras ((- Siding(C7� Sher 1 rj
t ,
i Bnf f f 1r r7 pFton Of Proposed
t Y"i f)(k � 4..Rb+�!_ 11..��__ ,j f _ � ��s. ...-. 1 w W ° t ♦ i.:�l��
Ajte Ajwi of e_-xisitr)g idrn%c,: ...___ 'f o`___.._. °vcr Adding:.ew fodrCKIrn t v NO j
Attached 1Vat'et-,ve He rcvening urrfimnhe,d ira5ewent _r°�._ y f> __---_No
Hans Attached Roll -Slse�et
i
j 6a If New house and or addition to existirEtt�e�serx�� orr��s�e*t�the#call��erirrt�
a H-e of Jwldir g Ono c" t
<s art„' v1^?
f _ '
Ni gntpr of r�cm'. t r=act•fAmil imit
t � Y
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I Is there.a garage'at°,adte,V
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( f Method of heat,nq'? _-_ _ _ _._ F of�3rCi r,;'v1lt':xf�f ves _Pii,nt C'of e act 3
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ck !`nerGy Ctsnsnrvatirn Gottiptrt3ncx- "il0asscr,erat. i:rteigy xru
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7 t-� gyp!✓' �!t.�tl fit? t2tr,n_.,
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L3s0 n Yes
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( t7enth of tiasemew or cellar P,tK W.;w t?i a gJael r
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i+, Will t>utldi,.0 r;r}ofc;tra?±c fre F?tn1{dir q nnc'"orrnq rt-gt,tatrt;trs'
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SECTION 7.-OWNER AUT RRiZAi'” ,TJ BE CCMP'LETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
t
�f� i Uc,i;wt,��sit the st+tatgf-f
!u�of no behalf in A n-tWl(rs rciatsw_=tc,��wk'-,ligc razed by t:IN ou?IClr iq V rrntt aPApiu,3is:a„
_ . _.
! g taiure Of Q*Twt Jax-
aF Ciw e'r;Aoaho;taed
i 49e r.,ftert_ry the rat_,anvil exittxvrt<jmti;fn t#te fixegotnq to the to t of my lanttw4+eclge
artd belie;
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Signed under the pains and g>-nallw of p',"Qury
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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: L: R:
Rear
Building Height
Bldg.Square Footage o
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 Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wettands? NO Q DONT KNOW 0 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 Q NO O
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 0
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 Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Deparime-nt uzw o,-Oy._.._.
f� City of Northampton of Pe'rn t
..S Building D-,-partrrK-tat Curb CutiDirvpway E eTrrlt
212 Main `Jtrept
Northampton, IVIA 01 06 'Wv) :ets of,tru l a Plans
Q- E phone 41 3 587 °314(7 Fax 413-587-1272 1Pirt7'ite Pinta
PPL ICA71ON TO CONSTRUCT,AL ER,REPAIR,RENOVATE OR DE118SDtAS€7 A ONE OR rAO0 FAMILY DWELT INN
i -SIDE INFORMATION
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`9 i This section to 6ae completed tr office 1
Propert�,Arir4
Map imt V
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Lttn St_Distno _.._ _ Ce Mmnc,t i
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SECTION 2-PROPERTY t?SI NERSHIP/AuTHORIZED A GEN
2.1 Owner of Record, i
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dmt ,nt! ur e .Pa 3 hn3
# 7,2 Authorized AgeAlt: t. r, .'T '+a
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SEC7i t4 3-E7�k#ATE3UNa-7FtLiCTiOI CC?S5 #
1t+,n Fsrrz med c=*s \ma ,p te;ne
ly
§ •m,e t L by perP,t a ?irar2 i t g
it.id m ia;Bu,ti'!ig f Arent i'th' 11;
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r' E`i-rtr cal ._._._. obi Fstirnated rot,-al(")r .i _aP �(--
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1 Smiding Pemut Fee
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4 A h inic.ai!HV,4(,) j
Fire Protecfaon
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Total t 3 +a
Cher*Nu be
1his Section Fox Ofttciaf Use Ony If � I
# t1 atr #
Ru: t r g Pe m,t Numbe _. ._..__ _._ _. t 5uetcP,__
lna Ure _.... ....____._..
t:-lift,tr!� ,i) it .4ti'+CA:" A `i�l�`;:t ti( .t itF+•7!'}{1 z• ialc'
File# BP-2015-0364
APPLICANT/CONTACT PERSON TROY ST PIERRE
ADDRESS/PHONE 18 ST PIERRES LN WESTFIELD (413)454-0019
PROPERTY LOCATION 91 EMERSON WAY
MAP 36 PARCEL 358 001 ZONE
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: FINISH BASEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 101969
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
proved 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
D it 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.
91 EMERSON WAY BP-2015-0364
GIs �,,: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-358 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2015-0364
Project# JS-2015-000673
Est. Cost: $9000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TROY ST PIERRE 101969
Lot Size(sq. ft.): 12414.60 Owner: DAWSON KIMBERLY
Zonin(: Applicant: TROY ST PIERRE
AT. 91 EMERSON WAY
Applicant Address: Phone: Insurance:
18 ST PIERRES LN (413) 454-0019 WC
WESTFIELDMA01085 ISSUED ON:101212014 0:00:00
TO PERFORM THE FOLLOWING WORK:FINISH BASEMENT
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 10/2/2014 0:00:00 $55.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner