17C-276 9 d ,f�lassncllnsrlla' -
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building <'
Northampton, I1lass. 01060
VrrORTti'�E.�R'S COMPENSATION INSURANCE Ali 'c AVIT
I, Pioneer Contracf-ors
(L cen-ser�Pelm�tree)
,xith a principal place of business/residence a-t:
P.O.__.Box 1145 NnrthAmnton _ MA n1,n61 (phoney) 586 54-91
(strut/city/s�cale/zip)
do hereby certify, under the pains and penalties of perjury, that.
( ) I am an employer providing the following worker's compensation coverage for my
caiplo),ec5 worming on this job-.
Wcc 500595701200 6/30/041
Assoc'] ated Employers Tns __, _
(Insurance: Company) (Policy Number) (E.a-pimdon Date.)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (lnsuranoc Company/PoUcy Number) _ (F_,,#ration Date)
(Name of contractor) (Insurance Compan}y/Pobic)r Number) (Expnuou Date)
(Name of Contractor) (Insuranc—_ Company/Policy Number) (E1•piranou Date)
(Name of Contractor) (Insurance Company/Poticy Numbcs) (Expiradon Date)
(anaeh additicna!theet ifnax=a to ine} mformation Pe_J ning Well matry ,t )
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that wt�do homc+owncn who czuplay persons to do�irrim,occ o=5u%rcuoo or rgma r work w a dwelling of
not mom then throa unity in NKimch the homoowncr rtsidca or oa the grounds apputtenan1 theme art oo(gwaally oo=dcrtd to be
employcrs under the wocka s«capcnsauca qrt(GL152,s31(5)),aWLicadcm by a homnowvcr for a Ucca3c or pm=A may nid.cc U4
legal ctaara of as employe under the Woricora CompaouAjoa AcL
I un&W: d rhst a.copy ofthia aatmocut may bo forwarded to coo Dcparmmt oflndus5ial Aocidmrl OfBoo of h"ws orn for the
coverage vcaficstiou and aut failurc to want;covctxgo under soaloo 25A of MOL 152 can Ind to tho imposition of aimmal perultics
oomutin of a fmc of up to S 1,500.00 andlor imtuisoamcnl of up to ow year acid civil pcsaltics in the force of a Stop W on Orcic and a
fins 0(51W.00 a day against mc.
For dcpuunztal uac 0a1Y
Permit Number
9 _lit
rs SiPa of Liccns<�JPemitt= e ----
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: 1�3 v�I'll ok,�RcL2
License Number
P v RL I t� , �:� , r�,�f�c 1 1 1,,.l w1 l>
Address Expiration Date
Signature I pho e
9'Reaistered Home Improvement Contractor: Not Applicable ❑
T)cx,'A- K kax V3 9(:;�I
Company Name Registration Number
el j 12_ ?c7G
Address Expiration Date
Telephone at, SUrG 1_
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...... ❑
110 -Rome Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellines 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 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 Parkin Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON T KNOW YES CD
IF YES: enter Book ! Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW C) YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 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 I0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [OJ Decks [Q Siding[m] Other[a]
Brief Description of Proposed
Work: Install new window in cxisitng wall
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
6a.if New#rouse and or addition to existing housing, complete the follow n.
a. Use of building: One Family X Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? Yes
d. Proposed Square footage of new construction. N/A
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 X 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 as Owner of the subject
property
hereby aut rize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner 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 /Agent Date
• r���'��ri X�.ri�x�:� �'��'�'��'�a�Ge� :� �a� ,,. �k V�'w"�. r ns 9,
City of Northampton 8 �Wu SIOMP
Tti"i, s���`tia
Building Department curb �i f
w fir,
212 Main Street e�N"� 1
Room 100 a• ��,
Northampton, MA 01060 `w
phone 413-587-1240 Fax 413-587-1272
�
ML�.St H
APPLICATION TO CONSTRUCT,ALTER,REPAIR,R NOVAt OR f MOLiSH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION ��$
1.1 Property Address: C; This se on to be completed by office
1a
Mep=.-1 'l;t\\ Lot Unit
r
D F; Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Margaret Lloyd &John Bollard 17 Lilly Streettf �p�t
Named ) Curr7-2Zn9 -o6�/t 6 `► -2,-7j'2-
Telephone
Signatu
2.2 Authorized Agent:
Pioneer Contractors b gthc I t 4 j D-AVIA Mn 01 b10 t
Name(Print) Current Mailing Address:IV 5�-' SL}Ol l
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 2,000 (a) Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
S. Total=(1 +2+3+4+5) Z Check Number
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2009-0366
APPLICANT/CONTACT PERSON PIONEER CONTRACTORS
ADDRESS/PHONE PO Box 1145 NORTHAMPTON (413)586-5491
PROPERTY LOCATION 17 LILLY ST
MAP 17C PARCEL 276 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid lalf If
Ttipeof Construction: INSTALL NEV WINDOW
New Construction
Non Structural interior renovations
Addition to Existing
AccessoEy Structure
Building Plans Included:
Owner/Statement or License 017890
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF¢RMATION 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
10 02
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.
BP-2009-0366
GIS#: COMMONWEALTH OF MASSACHUSETTS
� T ,,, . CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0366
Project# JS-2009-000491
Est. Cost: $2000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group PIONEER CONTRACTORS 017890
Lot Size(sq. ft.): 11456.28 Owner: BOLLARD JOHN K&MARGARET G
Zoning.URB Applicant: PIONEER CONTRACTORS
AT: 17 LILLY ST
Applicant Address: Phone: Insurance:
PO Box 1145 (413) 586-5491 Workers
Compensation
NORTHAMPTON MAO 1061 ISSUED ON.101212008 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL NEW WINDOW
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 10/2/2008 0:00:00 $35.0012871
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo