18-041 (6) SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: .. __ Not Applicable ❑
Name of License Holder: ,J�"t�w�` – 7 -1160
License Number
Address Expirat on Date
/"4--A—t—�4
Signature Telephone
9,., isterdziH[1t>e.l�iira�rmenlGcntrator Not Applicable ❑
ISZ-1841 -7
Comifty Name Registration Number
Address EE p tion 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...... ❑
ome:,Owner Exemotion
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 applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding[0] Other[O]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes__IZN o Adding new bedroom Yes L- No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ga. 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?
d. Proposed Square f of new nstruction. Dimensions
e. Number of stori; s?
f. Method of he ting? Fireplaces or Woodstoves Number of each
g. Energy Cons rvation ompliance. Masscheck Energy Compliance form attached?
h. Type of cons u ' n
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, lti I GL1 A k-' g ern VAIJ , as Owner of the subject
property
hereby authorize �� i�0�-�
to act on my behalf, in all m ers relative to work authorized by this building permit application.
> S""
Signature of Owner Date
as Owner/Authorized
Agent here 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.
5 1-'ek �.. ';:� , s�
Print Nam
S' re of Owner/Agent ate
tw�
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 tilled in by
Building Department
Lot Size
Frontage
Setbacks Front /
Side L: R: _. 1 : . R:
ear ;
r
Building eight ;
Bldg.So Aare Footage
Open S ace Footage
(Lot area inus bldg&paved
parking)
#of Parki Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Findin ever been issued for/on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:':
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained l Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 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 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
Fr City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
3 2��� 212 Main Street SewertSepticAvailability
Room 100 Wate*011 Availabilit�r
I Northampton, MA 01060 Two Sets of Structural Plans
r'I &Gas inspections
MA 01 Obone 13-587-1240 Fax 413-587-1272 PlotlSite 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:
LC yC /g✓-� Map Lot Unit
/Z-1 /o Zone Overlay District
/v Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.11 Owner of Record: l ^
Name(Print) Current Mailing Address:
/1,( CAL44 TA,l tAM Telephone
ignature
2.2 Authorized Accent:
Name( mt) Current Mailin Address:
4nrLe e 6 Telephone �71 -1 1
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted permit a licant
1. Building ts� (a) Building Permit Fee
2. Electrical cli (b) Estimated Total Cost of
Construction from 6
3. Plumbing ,�t�� Building Permit Fee
4. Mechanical(HVAC) D
5. Fire Protection
6. Total=(1 +2+3+4+5) my Check Number 6
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: -
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0723
APPLICANT/CONTACT PERSON STEPHEN D ROSS
ADDRESS/PHONE 36 SERVICE CENTER RD NORTHAMPTON (413)584-1224 Q
PROPERTY LOCATION 164 COOKE AVE
MAP 18 PARCEL 041 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiny,Permit Filled out
Fee Paid
T_ypeof Construction: INSTALL KITCHEN CABINETS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included: -
Owner/Statement or License 079160 /�C
3 sets of Plans/Plot Plan ( r►'�Y
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INJ79RVIATION PRESENTED:
Approved 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
e
Si e of uildi O icial 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.
.,,01
164 COOKE AVE BP-2015-0723
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18-041 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2015-0723
Project# JS-2015-001403
Est. Cost: $16100.00
Fee: $96.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: STEPHEN D ROSS 079160
Lot Size(sa. 1): 26353.80 Owner: BERNHARD MICHELE TURNER
Zoning: Applicant: STEPHEN D ROSS
AT. 164 COOKE AVE
Applicant Address: Phone: Insurance:
36 SERVICE CENTER RD (413) 584-1224 O WC
NORTHAMPTONMA01060 ISSUED ON.•1 11512015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL KITCHEN CABINETS
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 1/15/2015 0:00:00 $96.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner