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17C-323 (5) loom City of Northampton Building Department 212 Main Street Room 100 Northampton; MA 01060 , .f phone 413-587-1240 Fax 413-587-1272 - APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1, SITE INFORMATION - TI)j" g 1.1 Property Address: oon to b' come16ted b y office !1A U I P,h 1 41 Lam' •• Tone'" � � �Overlaq D>s"`frict a __ tti S�Dtnct �1**u,-v w..> CB."District fifififififi SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1--Owner of Record: Ll �J�'• S� -_. I` tMN L Lila�° .5T rY' �tl�'t'i'7C :�"7 Name Pnnt.,.- cu rre ailina Address Z/g L!/ ,. / Telephone 3 g 2.2 AutWri:f&d Aaent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3 `ESTIMATED CONSTRUCTION COSTS` Item Estimated Cost(Dollars)to be Official Use Only com leted by ermit applicant 1. Building (a)Building:PermitsFee 2. Electrical c2V p -0)Estimated Total Cost of �`�i Con"stcuction from►..Fi 3. Plumbing L� G� Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) (� 000 Check Number 0 T Is Sectlibri For Otiriclaig Use.Onl Dote Building Permit Number. Isiued: Signature: r i Building:Commissioner/Inspector of Buildings Date A. Section 4. ZONING All Informatiiih 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 ' `---d3 S7 1 Setbacks Front I- ; Side L: R: " L / ^ R:F Rear Building Height Bldg.Square Footage yr 1 1_:1 _ Open Space Footage (-I! />~241 1,,,, (Lot area minus bldg&paved _ l azkin n �] #of Parking Spaces Fill: (volume,&Location)' A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:', IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book '� Pase j and/or Document# �� { j B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 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 0 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. Iii ..fit SECTION-5-DESCRIPTION OF PROPOSED WORK(check all,am5l• abW New House Addition ❑ ; Replacement Windows Alterations) Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [Q Siding [0] Other[cl] Brief Des iptior�of Proposed Work: ��:101 c� 'S{�r y YjcQzxm �►✓�'�t/t' Tz"»��`� �'1�.✓►��� 0 Alteration of existing bedroom Yes v--'No Adding new bedroom Yes I' No .v-_ "No Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roll -Sheet sa.`If I�ew=�orase�an iac[i��on �sfi�n ou`s�n m �etexthe�faf Q�ln a. Use of building:One Family Two Family Other b. Number of rooms in each family unit: yto Number of Bathrooms c. Is there a garage attached? e5 If z d. Proposed Square footage of new construction. S dimensions /J X.3 6 e. Number of stories? f. Method of he Fireplaces r Woodstoves e5 Number of each -� g- Energy Conservation Compli nce. a sc eck 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 r No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Z,afSing regulations? Yes No. I. Septic Tank City Sewer t Private well City water Supply ti// SECTION 7a-OWNERAUTHORIZATION-70 BEGOMPLETED EN OWNERS.AGENT TQR QR CONTRAC APPLIES FOR BUiLDtNG PE MIT as Owner of the subject property hereby authorize 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. �e SSA_-,��n��►�['`� ..- Print Name gnatu f Owner/Agent ate z r SECTION 8-CONSTRUCTION',AERVICE"S i 8.1 Licensed Construction Supervisor: / Not Applicable ❑ Name of license Holder: E'SSe = Cf 077 4110 License Number /vrrIx C /1A v r cam,if-- C9 , e),5 Address - Expired a re _ Telephone egas�tee o pr en�e� t ado Not Applicable ❑ - - Company Name Registration Num a– — –-- r - 4-(o a S /(7 /q &,5: Address Expirati Date ,�J7'ri1Cc Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G L.c.1'52,:§"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...... ❑ 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/sbe 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 r i i Rt twr nr f.. �. F E 1J�71� LT� ��CIZ"�Iji�lll�)�Dll _ _ B J E �'�c�:etch RtrttD © DEPARTMEI-rT OP BUILDr)\,G INSPECTION'S 212 Main Strcet Municipal Building Northampton, Mass. 01060 WORKER'S COi\TPENSATION GISURANCE AI'r A.VI71" 1 •. i ccns,�Jperm�tt'cc) ,%rith a principal place of businessfresidence at. ------- t( 01k f —L1 ct (sc=&C1 ty/stalc/z�p) do hereby cervfj, under tlic pains and penalties of perjury:, hat I ( ) I am an employer providing the following!-,vork&s comocnsa;.ioi coverage for Iny ta3piovees NvorUng on uiis job: (I>�nir_ac Conr:n,) (Pclic: Nu r) (7:--,pirroon Dom) r ( ) I am a sole proprretor, genera] contraaor or homeow-Der (c cie one) aoo have hired the conrra(nors listed below vqho have the fpllo�ving wor ens ramoen_t2:lion pa!icies: ONamc Of CO„^ci0r) (IRStmnc; CompaJy/-Pobci NILLML'C) (i?:a1TdRQR D1lC} I i (Name of Concramor) (insurance (La-pirrtion Dam) i (Nzme of Co=da;): (Laurance Com /Po0 Nambu) (Exairtioa Date) (Name of Contactor) (aurae-- Comcany/Policy Numbu) k7i-pirdcioa Dail)- ' (nQiS�:.dot.:t]C1.1 s�CC1,lf acG�1.a_1'LD 6)GVG�talot-C1a`l oa�-�lyyyZj.s In�rf ooa7-Ln:7I - { am a sole proprietor and have no one worm g o f r me. ( ) I am..a home owner performing all t.be 1'vork myself. i NOTE:plesc be Lw-xm the +fntc bemcaµam a bo cmplay pc Lcm w Lo—ing - c=,:.uoo cr rc nr work ao L d.•tlL^ of tux tnoct tbsa t.fm��w�'seh the bornoowoc rteda a oa tb.c ipj-ouaGs zppurte*+-+-+the^ea�i noe mss..:-lly a�crid�l to be axploy,un2c the--S;r 0==pc -+:ca Aa(G LA 52-s 1(5)�:pptintioa by n bomc*Qaa rct-tie—_or pama>=y c-idmcc the Ic-pr OAZ.of La crPloyer trader dy-W*Ik-e-Compomat Act_ j 1 undcstaad th.t>ooyy of tbia——y bo f--,,3—d to tba Dc _,.>cat orIadsstrid ALCd OT._of 4 +Noce ror the- --F vc•if c=ioa and tlu L-ikaz to Ac=m bovcrnCc uad-- 25A of MGL 152 c=lad to the impositioa cd a imiaA pcn>Wx 000scsnzg of a fiat orup to SI}00.00 utdloc 6mPr6oamc=orup to one yt:ar Lad avil pauhia is the form or&Stop Wort;Orxkr and a f=' of 5100.00.d.Ly tp T=me i For dc�u. oaJy Pcrmit Numb= Lot ' crn-Liucz e O�'tt1AMp�O _. G1 y of Nort4aniptan � j�lasssr}tusetfs DEPARTMENT OF BUILDING INSPECTIONS f INSPECTOR '212 Main Street • Municipal Build ng ' Northampton,MA 01060 N HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as I:is/her construction sup,. ,,isor. The state defines "Homeowner" as, "Person(s) who owns a parcel on which he/she resides or intends to be, a one or two fame y 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 home owner." The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection(before work is concealed), insulation inspection(if required) and a final building inspection.:The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work(electrical, plumbing& gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections.Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made L understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Daze Address of work location r i ' File#BP-2005-0861 APPLICANT/CONTACT PERSON Jesse Montgomery ADDRESS/PHONE P O BOX 329 LEEDS (413)585-8482 Q PROPERTY LOCATION 40 OAK ST MAP 17C PARCEL 323 001 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 11 Typeof Construction: CONSTRUCT 2 STORY SFH W/ATT GARAGE/PORCH New Construction Non Structural interior renovations Addition to Existing. Accessory Structure Building Plans Included• Owner/Statement or License 077410 3 sets of Plans/Plot Plan THE FO.LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Co ssion 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. 40 OAK ST BP-2005-0861 GiS#: COMMONWEALTH OF MASSACHUSETTS : k:17c 323 CITY OF NORTHAMPTON Lot: -001 Permit: Buildina Category: BUILDING PERMIT Permit# BP-2005-0861 Project# JS-2005-1195 Est. Cost: $156000.00 Fee: $961.75 PERMISSION IS HEREBY GRANTED TO: Const. Class: 5B Contractor: License: Use Groo: R4 JESSE MONTGOMERY 077410 Lot Size(sq. ft.): Owner: MONTGOMERY JESSE&HEATHER A Zoning:_URB Applicant: Jesse Montgomery AT: 40 OAK ST Applicant Address: Phone: Insurance: P O BOX 329 (413)585-8482 (� LEEDSMA01053 ISSUED ON:3123105 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 2 STORY SFH W/ATT GARAGE/PORCH 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 $961.75 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo