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38A-107 (2) SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑? Name of License Holder:_ ps II f License Number Address zk d ; Expiration Date Signature Telephone 9.Reoistered Home Improvement Contractor: Not Applicable ❑ \7D t'7�s t 1�y 10�L tai.,{2 1-7 A)l Company Name Registration Number C Address Expirat n Dat 1 Telephone 'cwt 724 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...... ❑ Home Owner Exempti©n 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 I Alteration(s) ZJ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding[O] Other[a Brief Description of Proposed Work: Alteration of existing bedroom Yes__.'�_ o Adding new bedroom Yes No / Attached Narrative Renovating unfinished basement Yes '' o Plans Attached Roll -Sheet 6a. If New house and or addition to existing housina. complete the following: a. Use of building: One Family Two Family Other / b. Number of rooms in each family unit: Number of Bathrooms L �j c. Is there a garage attached? IQ v d. Proposed Square footage of new construction. rN"Q Dimensions e. Number of stories? ' f. Method of heating? Fire ces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetl s? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cel oor below finished grade k. Will building co m to the Building and Zoning regulations? Yes No. I. Septi nk City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �f t/�4if ZL as Owner of the subject property hereby authorize to act on my behalf, in al otters relative to work authorized by this building permit application. C; 1 s', S Signature of Owner GZ 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. C Print Name Signature of Owner/Agent Date h � 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 epartment Lot Size Frontage Setbacks Front pk- Side L: R: L: R: �� Rear Building Height Bldg. Square Footage J. Open Space FootF&p e _ % (Lot area minus bldg d Arkin #of Park' Spaces ill: _. volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW YES 0 IF YES, date Issued: IF YES: Was t permit recorded at the Registry of Deeds? NO 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 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 NO IF YES, describe size, type and location: iti' y�r 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, exc tion,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. m, W k� a - Department use only City of Northampton Status of Permit: Q Building Department Curb CuiJbriveiway Permit 212 Main Street SewerlSapticAvailability: F8 -42� � Room 100 Water/1 7 11 AV rlability i orthampton, MA 01060 Two"W. of Structural-Plans h e 3-587-1240 Fax 413-587-1272 Plot/Site Plans t umbing&Gay iii hamp'_^^ ��A , CtltE:r peCiCy, APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION —7 This section to be completed by office 1.1 Property Address: i r t t tutle �/U Map Lot Unit K-)t, ,NUI` � Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: V1 a I z74 if i I(a i ll Poad -4101 ., Name(Print) Current Mailing Ad re s: Telep one Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: � p n 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 CC (b)Estimated Total Cost of O Construction from 6 3. Plumbing _ Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0776 APPLICANT/CONTACT PERSON ROBERT WALKER ADDRESS/PHONE 36 Service Center NORTHAMPTON01060(413)584-1224 PROPERTY LOCATION 11 VILLAGE HILL RD-#101 MAP 38A PARCEL 107 001 ZONE PV(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: ADD PARTITION WALLS-#101 New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building_Plans Included• Owner/Statement or License 034783 3 sets of Plans/Plot Plan cle ,-ec j %C , ah e v,` THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOjA¢ATION PRESENTED: ,*1*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 D lit'" Delay u it i 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. I I VILLAGE HILL RD-#101 BP-2015-0776 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38A- 107 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-2015-0776 Project# JS-2015-001515 Est. Cost: $18750.00 Fee: $112.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT WALKER 034783 Lot Size(sq. ft.): 38027.88 Owner: MAZZA GINA Zoning: PV(100) Applicant: ROBERT WALKER AT. 11 VILLAGE HILL RD - #101 Applicant Address: Phone: Insurance: 36 Service Center (413) 584-1224 Workers Compensation NORTHAMPTON MA01 060 ISSUED ON:21512015 0:00:00 TO PERFORM THE FOLLOWING WORK.ADD PARTITION WALLS - #101 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 2/5/2015 0:00:00 $112.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner