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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Dime of License Holder: Me5r !/C at 114 _
01,57Z7.
License Wurnber
Z,D gar'4,Aj e) A Z/Y�6
dress Expiration Date
2/ ,
Signature Telephone
Res md HoMe kWommement Cont>Ct lr Not Applicable ❑
Company Name Registration Number
zc, t6 M cFv�X r) i
AddFess 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 Own er 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
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all auolicablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) � Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks [❑ Siding[CI] Other[Cq
Brief Descri tion of Proposed^ i f
Work: g[AGe C-A bi t a S t N'. -A Ii U C_'J
Alteration of existing bedroom Yes-No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes X' No
Plans Attached Roll -Sheet
sa.If New,1»use»iixtci ox*Wltim to exist[rtt>I s cornalete the fe>Ikwvlma
a. Use of building:One Family_7V Two Family Other
b. Number of rooms in each family unit: i Number of Bathrooms �-
c. Is there a garage attached? Q Q
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? Z
f. Method of heating? Fireplaces or Woodstoves WO Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction �jv, 'N7izte,,,�
i. Is construction within 100 ft.of wetlands? Yes 2O No. Is construction within 100 yr. floodplain Yes No
t
j. Depth of basement or cellar floor below finished grade 8
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer_0 Private well City water Supply -IC2
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, KA 6Kalf as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner —r Date
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.
Print Name
Signature of Owner/Agent Date
mmow
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
arkin
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW YES Q
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book ` Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO P DON'T KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained O , Date Issued:
C. Do any signs exist on the property? YES Q NO
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
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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
i of Northampton
� I ing Department
�
17014 Nov
`P� Main Street
�s �oom 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 r � �
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
Map Lot Unit
zone Overlay District
Elm St.District C8 Distrlct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: _
Name(Print) Curre cling Ad s•
_ ho�s-o
Telephone
Signature
2.2 Authgdzed Ag4nt.•
me 'nt Current Mailin Address:
6
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 �S Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0574
APPLICANT/CONTACT PERSON FORREST DEVINE
ADDRESS/PHONE 20 HARTLAND HOLLOW RD GRANVILLE (413)214-8629
PROPERTY LOCATION 51 HENRY ST
MAP 32 PARCEL 028 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out go 40'a
Fee Paid
Typeof Construction: REPLACE KITCHEN CABINETS&NEW FLOOR
New Construction
Non Structural interior renovations Ivo
Addition to Existin
Accessory Structure
Building Plans Included:
Owner/Statement or License 95779
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMA N PRESENTED:
roved 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
De io
ur of ing O cial 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.
51 HENRY ST BP-2015-0574
GIs#: COMMONWEALTH OF MASSACHUSETTS
MM:Block: 32-028 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: renovation BUILDING PERMIT
Permit# BP-2015-0574
Project# JS-2015-001090
Est. Cost: $15000.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: FORREST DEVINE 95779
Lot Size(sq. ft.): 28009.08 Owner: HOPKINS MARTHA L&GILES S
Zoning: Applicant: FORREST DEVINE
AT. 51 HENRY ST
Applicant Address: Phone: Insurance:
20 HARTLAND HOLLOW RD (413) 214-8629 WC
GRANVILLEMA01034 ISSUED ON.121412014 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE KITCHEN CABINETS & NEW FLOOR
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 12/4/2014 0:00:00 $90.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner