24C-075 (3) SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable O
Name of License Holder: - � -7_�
License Num
4 2 7
Address Expirati Date
Signature Telephone
Ll 1 Z--t `T
9.ReLtered Home Improvement Contract r: ^ ! L Not Applicable[�0
Compfany Name Registratio Nu per
Address I Expiry' n Date
Telephone 5-6 Y-/ Z Z- y
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 wig 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 arid/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 behhe 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
N/ A - e�� a i' v---LA4"'�""' '-j 0` k-
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
B Iding Height
Bl g.Square Footage
Open ace Fo ge
(Lot area m s ldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW 0 YES
IF YES: enter Book Page and/or Document;r
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW ® 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 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 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 C]
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[p] Other(CQ
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes V No
Attached Narrative Renovating unfinished basement Yes Y No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the'followina:
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
I, /-" /`/ —�- G�I` ✓ e as Owner of tlts sect
property L I st
hereby authorize
to act on my behalf, in all mattipfrs relative t work u ized by this building permit applicat716,
t
Signature of Owner Date
as Owner/Authorized
Agent here 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.
�--
go s
Pri _
S ature of wner/Agent Date
ept�ttfrtt C
F CEIVED City of Northampton Status of Permit:
U 2 i T
Building Department Curb Gut/Driveway Permit . ,, .... °
JAN 9 2916 212 Main Street Sewer/Septic Availabi
Room 100 WaterlWell Arrailabilit*r �
Northampton, MA 01060 Two Sets of Structural Plaris
DEPT.OF BUILDING INS
PEMONJ s z
NORTHAMPTON MA01o60 ho 413-587-1240 Fax 413-587-1272 Plot/Site Plans
t
Otter Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Prouerty Address:
This section to be comp"d by o. W
3G /j't��SchSv r" - S�✓�°` Map Lot ..,.........,..
Zone Overlay DWbict ,,.,,,..
Elm St.District CB o
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print). Current Mailing Address:
� " A'� Telephone
Signature
2.2 Authorized Anent: 7 q
`(f` )
S� ��. Izs S 1 Ci- S{✓t!) ��c��✓- yC� �+ l'1.=• A���l
Na r ) Current Mailing Address:
ignatuW Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building eO (a)Building Permit Fee
2. Electrical cx> (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) U 9S
5. Fire Protection 1
6. Total=(1 +2+3+4+5) / - Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: — A
Building Commissioner/Inspector of Buildings Date
36 MASSASOIT ST BP-2016-0917
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C-075 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-2016-0917
Project# JS-2016-001557
Est. Cost: $8100.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEPHEN D ROSS 079160
Lot Size(sq.ft.): 15768.72 Owner: HIRSCH EILEEN B
zoning: URB(100) Applicant: STEPHEN D ROSS
AT. 36 MASSASOIT ST
Applicant Address: Phone: Insurance:
36 SERVICE CENTER RD (413) 584-1224 O WC
NORTHAMPTONMA01060 ISSUED ON:111912016 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE TUB W/SHOWER
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 1/19/2016 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner