23C-084 SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: 5��ah.•� JrJ. �( � 717 � D
License Num er
3 C-11 Address
Expir&ti&Date
atur Telephone
S.Retaistered Home Improvement Contractor: Not Applicable ❑
Compaffv Name Registration Number
Address QQ(l Expirati n Date rzy
Telephone
Z.2 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...... ❑
1L- Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(]) 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 buildine 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 E]
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [p Siding[❑] Other[❑]
Brief Description of Proposed / ✓��
Work: lZ a^,p .�, f�
Alteration of existing bedroom Yes No Adding new bedroom Yes No /
Attached Narrative Renovating unfinished basement Yes t/ No
Plans Attached Roll -Sheet
6a. 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 footage of new construction. Dimensions
e. stories?
f Method of heating. Fireplaces or Woodstoves Number of each
g. Energy Conservation Complia Masscheck Energy Compliance form attached?
h. Type of construction "
i. Is- ction within 100 fl. 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, � h- 1 C e e-v`- G k "'"-- , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters r lative tow rk authorized by this building permit application.
Signature of Owner Date
1, `U2' t"`` rZ. �-3 , as Owner/Authorized
Agent herebwoeciare 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
Z!?n-
1l ��
S nature weer/Agent Date 7/
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:'. ZL R:
Rear
Building Height
Bldg. Square Foota
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 DON'T KNOW 10 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW 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 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 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 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
ity of Northampton Status of Permit
Building Department Curb Cut/Driveway Permit
I
!1 212 Main Street Sewer/Septie,Availabli
L
21 2015 _ Room 100 wb er/VVell Availability,
L _
Noilhampton, MA 01060 Two sets of.StrIuctural Purls
Electric P�'r� pioie� a, 587-1240 Fax 413-587-1272 Pioite Plan
1icrtr a
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This This section to be completed by office
G S B� try J T✓-�-1 Map Lot Unit
G--a,. �` Z Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: / �^
,LNG
Name(Print) Current Mailing Address:
Telephone
Signatur0'—S-
2.2 Authorized Agent:
Name(Riffnt) Current Mailing Address:
G 51/T—
signat e
Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building �U G. C-1.3 (a)Building Permit Fee
2. Electrical tm (b)Estimated Total Cost of
Z� Construction from 6
3. Plumbing r c-/ Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection —
6. Total=(1 +2+3+4+5) pU. Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0740
APPLICANT/CONTACT PERSON STEPHEN D ROSS
ADDRESS/PHONE 36 SERVICE CENTER RD NORTHAMPTON01060(413)584-1224 Q
PROPERTY LOCATION 68 BLISS ST
MAP 23C PARCEL 084 001 ZONE URA(100)/WSP(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: REMODEL BATHROOM_
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building-Plans Included:
Owner/Statement or License 079160 I'
3 sets of Plans/Plot Plan C
3ApEFWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
ON PRESENTED:
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
Sig a ilding Of 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.
68 BLISS ST BP-2015-0740
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23C-084 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv:renovation BUILDING PERMIT
Permit# BP-2015-0740
Project# JS-2015-001443
Est. Cost: $13200.00
Fee: $79.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEPHEN D ROSS 079160
Lot Size(sq_ft.): 14157.00 Owner: KNICKERBOCKER ANN
Zoning.URA(,100,/WSP(100)/ Applicant. STEPHEN D ROSS
AT: 68 BLISS ST
Applicant Address: Phone: Insurance:
36 SERVICE CENTER RD (413) 584-1224 O WC
NORTHAMPTON MAO 1060 ISSUED ON.112312015 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL BATHROOM
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 1/23/2015 0:00:00 $79.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner