24C-044 (7) 7
�,:..
,c..;
� .. .?
i t:
Y>.
;,�• ,
f '..
;.:
" .r . J.,
�:
t
Scope of porch restoration:
I plan to replace the porch floor and the porch ceiling with custom milled material to match the
existing material. This includes 1 3/4" fir decking and 5/8"fir or pine t and g ceiling boards.
Existing deck framing is 2 x 10s on 24" centers spanning 10'. 1 will replace or add if any look
structurally compromised. The center 5" x 8" carrying beam has been cut at the end so I will
need to add a concrete footing and a post to support the beam. I will use a 10" sonatube for the
concrete.
I believe the Historic Commission does not require a hearing as there will be no changes to
materials or appearance.
III
y
�sY y
J p
i r
aG
The Commonwealth of Massachusetts
Department of Industrial Accidents
W
Office of Investigations
I Congress Street,Suite 100
1' Boston,MA 02114-2017
M www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /�� Please Print Legibly
Name (Business/Organization/Individual): / 1'iCh CI`t
Address:, Q S.�5
City/State/Zip: M& U,Q Phone#: T3 W5 7 ,2-
Are you an employer?Check the Japliropriate box:
4. I am a general contractor and I Type of project(required):
1.❑ 1 am a employer with ® g 6. ®New construction
employees (full and/or part-time).* have hired the sub-contractors
2.1P I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have g. Demolition
working or me in an capacity. employees and have workers'
g � y p tY comp.insurance.: 9. Building addition
[No ireodrkers comp. insurance 5 ® We are a corporation and its 10.®Electrical repairs or additions
required.]
313 1 am a homeowner doing all work officers have exercised their 11.®Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.[3 Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 1313 Other
comp.insurance required.]
"Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: _
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify and the pains a e es of perjury that the information provided ab ve is true and correct.
i tur : o
Date:
l�
Phone#: "1 1,3i �i CAS
Official use only. Ito not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Super1visor: Not Applicable ❑
Name of License Holder: i4�t�J 4 —10 vtx /
j s S ce 61 7Y
License Number
Ak S-h]btot:7
Address Expiration Date
Signature Telephone
Q. Registered Home Improvement Contractor: Not Applicable ❑
Comoanv Name Registration Number
h01-2,01X
Address p Expirati Date
Telephone j,3 �vs 797-7
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....... Pk 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [CA Decks [0 Siding K:]] Other[P6
Brief Descri tion of Pr pos
Work: U _ 'i 0 1 r L mck4 n
Alteration of existing bedroom Yes _No Adding new bedroom es k No
Attached Narrative I Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
F_6a. X S if New house and or addition to existi�tal housing,tamale#e the foltowing: f L Q C �S91�c
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. Number of stories?
f. Method of heating? Fireplaces 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 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
1, � t 2 (5 'S
as Owner of the subject
property
hereby authorize 04.0
to act on my behalf, in all ma ers relati a to work authorized by this building permit application.
4!�Z_a Z= gy I I I
Signature of Owner Date
I, tc).- /.1; 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.
any 5
Print Name f
-7)/ 1-
�-- S
Signature of O er/Agent <' Date
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
u Building Department
Lot Size s�"t Sp $4,
Frontage 41
Setbacks Front q i
Side L: ` R: S_ L: R:
Rear 13-7
Building Height ,37
Bldg. Square Footage ySS y %
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 O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O 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? YE£ O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
� ' Building Department Curb Gut/Drivewsy Permit
AW ( 12015 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Electri �� �,� ����� ;,k��G orthampton, MA 01060 Two Sets of Structural Plans
&�13-587-1240 Fax 413-587-1272 Plot/Site Plates
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 section to be completed by office
F I]M T
S J Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: t �, ` ```(
9?.cA-rti Q- d S�Q�- 33 3 GIcy, S. - M0,4arn_
Name(Print) Current Mailing Address:
/ _SRS - ii (1C,
Telephone
Signature
2.2 Authorized A nt: N b J dv1 e-5 4E '-ve"k c4, rte-f—
Name(Print Current Mailing Address:
X13 -1 y)J
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building O'n) (a) Building Permit Fee
2. Electrical v (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) �S
5. Fire Protection
6. Total= 0 +2+3+4+5) 0a 0 Check Number
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File# BP-2016-0170
APPLICANT/CONTACT PERSON NICHOLAS JONES
ADDRESS/PHONE P O BOX 515 WHATELY01093 (413)665-7927
PROPERTY LOCATION 333 ELM ST
MAP 24C PARCEL 044 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid dg
Building Permit Filled out
Fee Paid
Typeof Construction: RENOVATE FRONT PORCH (REPLACE DECKING &CEILING W/LIKE MATERIAI,)$A*w A?{
I�F�ER-RE�I'iE�74 fT�3 �ibinTo.4 .�j�I�! M.ct3�p M/Cj-C:}{
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 066878
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO MATION 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
Demolition Delay
(_ Z, Slabs-
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.
333 ELM ST BP-2016-0170
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C-044 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-2016-0170
Project# JS-2016-000292
Est. Cost: $6000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: NICHOLAS JONES 066878
Lot Size(sq. ft.): 54450.00 Owner: O'SHEA DANIEL J&BEATRICE H
Zoning_URA(100)/ Applicant: NICHOLAS JONES
AT. 333 ELM ST
Applicant Address: Phone: Insurance:
P O BOX 515 (413) 665-7927
WHATELYMA01093 ISSUED ON:811312015 0:00:00
TO PERFORM THE FOLLOWING WORK:RENOVATE FRONT PORCH (REPLACE
DECKING & CEILING W/LIKE MATERIAL) same appearance, need before & after photos & railing
must match
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 8/13/2015 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner