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38B-249 (2) SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Appliitc�a1ble ❑ Name of License Holder: L� y A 4—7 License Number Address Expiration Date Signature Telephone 9 Reaistered Home Improvement Contractor. Not Applicable ❑ Company Name Registration Number S-/ 1 4--1 Address Expiration Date Telephone �;e',P 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. •• 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,1rovided 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 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: C)-- , 4- -� 9-5 License Number til Address Expiration Date Signature Telephone 6.Realstered'Home Improvement Contractor: Not Applicable ❑ 4^ l 1 Z0 Company Name Registration Number Address` Expiratio Date V\A IN- Telephoned 12 2,4 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...... ❑ 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 El Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[ Brief Description of Proposed Work: Co s�cl• tom -(-r- k Alteration of existing bedroom Yes___Lf�No Adding new bedroom Yes v--1__� No Attached Narrative Renovating unfinished basement Yes o Plans Attached Roll -Sheet Ga. 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 c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensio e. Number of stories? f. Method of heating? F' laces 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 ands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement liar floor below finished grade k. Will build' conform to the Building and Zoning regulations? Yes No. I. ptic 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, "]'r1P,-r`'t� 1 V, t_11F 1C as Owner of the subject property hereby authorize 7c"931c. -X w to act on my behalf, in all maters relative to 1�qrk 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. l-C Print Name Signature of Owner/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 fille by Building Departme Lot Size Frontage Setbacks Front � Side L: - R: L: Rear Building Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg&paved parking) #of Parking S es Fil plume&Location) A. Has a Spec' t Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW 0 YES IF YES, date issued:'`.. IF YES: Was the permit recorded at the Registry of Deeds? NO 0 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 DONT KNOW 0 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 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, excavafion, 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. (�epartrnertt ttse I • � City of Northampton tts of Farmlt Building Department urb Ctttf( y Permit 212 Main Street Seuvsr �pttcAt �f Room 100 Water/1 fell.AyaifabrlltyA Northampton, MA 01060 of ttliotaral Plans PU - on 413-587-1240 Fax 413-587-1272 Plotlst , a e' ify "" y 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 2- '> 9—: T- Map 39,& Lot_�— Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: -ro f}N N f-1Q__ J Zol /A t S►`+j F A (LV f u}- Name(Print) Current Mailing Address: Telephone Signature 2.2 Authori ed Agent: �i �t;Q�i�r,Q�t 1Pcc.l� J�o (2-�l Name(Print) Current Mailing Address: VLA LA 13 ' 37b4 lZL- 4 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building C. (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 6. Total=0 +2+3+4+5) $ O t3 Check Number This Section For Official Use Only Building ermit Number: Date g Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2016-0514 APPLICANT/CONTACT PERSON ROBERT WALKER ADDRESS/PHONE 36 Service Center NORTHAMPTON01060(413)584-1224 PROPERTY LOCATION 23 OLIVE ST MAP 38B PARCEL 249 001 ZONE URB000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out y Fee Paid Typeof Construction: REPAIR PORCH&RESI L T REAR WALLS 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 THE FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 o ' ' n elay /d ld s 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. 23 OLIVE ST BP-2016-0514 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B -249 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-2016-0514 Project# JS-2016-000857 Est. Cost: $25000.00 Fee: $163.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT WALKER 034783 Lot Size(sq.ft.): 9801.00 Owner: TIGNER JOANN zoning URB(100)/ Applicant: ROBERT WALKER AT: 23 OLIVE ST Applicant Address: Phone: Insurance: 36 Service Center (413) 584-1224 Workers Compensation NORTHAMPTON MAO 1060 ISSUED ON:1011912015 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIR PORCH & RESIDE LEFT& REAR WALLS 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 10/19/2015 0:00:00 $163.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner