28-031 (2) f
78 CAHILLANE TER BP-2016-0969
GIS#: COMMO.1gWEALTH OF MASSACHUSETTS
Map:Block:28-031 (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-2016-0969
Project# JS-2016-001644
Est. Cost: $4500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAILYN GONZALEZ 97254
Lot Size(sq. ft.): 11761.20 Owner: BELL CLAUDE E&JANICE M
Zoning: Applicant: JAILYN GDNZALEZ
AT: 78 CAHILLANE ER
Applicant Address: Phone: Insurance:
44 BEEBE RD (413) 455-9944 O WC
MONSONMA01057 ISSUED ON:2/2/20166 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL KITCHEN & BATH
POST THIS CARD SO IT IS VISIBLE FROM THE $TREET
Inspector of Plumbing Inspector of Wiring D.P.W.I 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 2/2/2016 0:00:00 $65.00
212 Main Street,Phone(413)5$7-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-0969
APPLICANT/CONTACT PERSON JAILYN GONZALEZ
ADDRESS/PHONE 44 BEEBE RD MONSON01057(413)455-9944 O
PROPERTY LOCATION 78 CAHILLANE TER
MAP 28 PARCEL 031 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
Eh1CLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid _
Building Permit Filled out
Fee Paid
Typeof Construction: REMODEL KITCHEN&BATH
New Construction e
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included:
Owner/Statement or License 97254
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOR TION PRESENTED:
pproved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDEkR:§
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
i ' lay
400
_A<
Si e A<u' din f cial Date
Note: Issuance of a Zoning permit does not relieve a appliclant'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.
lk
._, 2f�K RA B US
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City of Northampton Status ofPermrt
V�0 � r �l��a'h� t��r9 �� - i wiry �.t'•�LM r�i r ' '
FEB _ 2 Building Department c.1, Cut/DrirrewayPerini#
ti 1 '9''Iii 'S-> >i -
212 Main Street Sewer.5060Auaira611ttK
Room 100 w , + L ,
Vllater/UlfeTtAvatla6ihtj�r' r,
DEPT,CF QU'.U j trq` T oNS
Ncn Nar��ron,n+Noic.:a rthampton, MA 01060 TwD,S�t`s otStrctct�Ta1 T'..-' ' �7 h t' lrF
P 4 Piot/SifB
4 t
one 4 3- - Fax 4 3-587-127
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENO V TE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION
This secfion to be completed,by office
1.1 Property Address: r
CcghI�IQ►�� ✓, ap Lot r' Unit
CI 1^
, r
I Overla D►strict ' 3
_ one y
SECTION 2.7 PROPERTY OWNERSHIP/AUTHORIZED AGENT:
2.1 Owner of Record:
�J Ccd�1t ���1YlP 1 i� �'Jt��r,Y�tIQ
Name( tint) CiOrrent Mailing Address: 141 5 80- elft b
T lephone
Sig atur
2.2 A thorized Agent:
v
Name(Print) Cdrrent Mailing Address:
Signature T lephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Feb
2. Electrical (b)Estimated Total'Cost of
Construction from(6):
3. Plumbing Building Permit Fee y/ e
s•4. Mechanical(HVAC) 66
5. Fire Protection
6. Total=0 +2+3+4+5) Lf S,7)t.i .-1J Check Number
This Section For Official Use Only
Building Permit Number. Issued:
Signature:
Building Commissioner/inspector of Buildings: Date
I
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
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bIdg&payed
#of Parking Spaces
A. Has aSpecial Permit/Va ria ms/Finding ever been issued for/on the site?
x~�x ��
� ���
NO «��~� DONT KNOW x�� YES
IF YES, dateissued:
IF YES: Was the permit recorded at the Registry ofDeeds?
NO "_~� ] DONTKNOYY 0 YES
IF YES: enter Book I Pagel and/or Document#
��
B. Does the site contain a brouk, body ofvvaternrwed ��wetlands? NO �~� DONT KNOW �~j YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ��/�~\ ��Obtained �-x Date~` / .
` �~�
C. Doany s�nsex�tonthe pmpprb� �-�YES �,� NO \��
|FYES, describe size, and location:
D. Are there any proposed changes tonradditions ofsigns intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, gradingexcavation,orfilling)over 1acre oris itpart ofocommon plan
that will ao,n? YES K ) NO
' ^~�
/F YEG,then o Northampton Storm Water Management Permit from the DPW is required. �
'
^ ~
�
.
/
|
/
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'
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all appligable)
New House ❑ Addition ❑ Replacementr�,ndows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [ ] Decks [C] Siding [O] Other[1%
Brief D scription of Proposed
WorkIcyruJ,ir cicl C-,rwk cinci nkll (leW gnei , ►nsfd '� )ii Irl-� inAogy_Pl000'Q� insk,(l newcecuni
r eYnJ -6"xV0,(v��Vbewyn
Alteration of existing bedroom Yes No Adding newbedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a lf. Neu4 house fid"or addifion tolexistinc>I.h"oasing; c rnplete the followinciF:
a. Use of building : One Family It Two Family (Other
b. Number of rooms in each family unit: Number of Pathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. V ' Y Dimensions
e. Number of stories?
f. Method of he@ting? G Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Massoheck 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 N(
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 WHaN
OWNERS AGENT OR CONTRACTOR APPLIES FOR.BUILDING PERMIT
4 hG as Owner of the subject
property l
hereby thorize �Gtkur1 (CI)XIII(Acyr6tfLj� �� Com!
to act n y behalf, in all mhttpfs relati tow k authorized by this building permit application.
Signat a of Owner Date
i
I, �Q I'1�t C a �� 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.
_ an0'I"C -
Pri me
6 -C)Z 4V�
Signa re o Owner/Agent Date
L �
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License HoldeGoin`I q CIS 1�')3 S�
License Number
Address Expiration Date
4'ice �'��
Si ture Telephone
N
9.Reoistered Home Improvement Cor►tractor of Applicable £
Company Name A Y Registration Number
14%-( �F 2�X ?-,(A '"�C� 1Z, Ory��� ZXO ' D1 1 -1(a
Address Expiration Date
Telephone � �
SECTION 10-WORKERS.'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§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..X.. £ 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.
I
The Commonwea th of Massachusetts
Department of I dustrial Accidents
Office ofhzvestigations
600 Washi� gton Street
r Boston, MA 02111
Y"f www.marss.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �( Please Print Legibly
Name (Business/Organization/Individual):
Address:_
City/State/Zip: i'A00U�, V) ul U S'1 Phone #: 4 SS'- 9 4 H
Are you an employer? Check the appropriate box: Type of project(required):
1.® I am a employer with f 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ['Remodeling
ship and have no employees These sub-cpntractors have g• ❑Demolition
working for mein any capacity. employees and have workers'
insur nce.� 9• ❑Building addition
comp.[No workers' comp. insurance � 10. Electrical repairs or additions
required.] 5. ❑ We are:a coVoration and its
3.❑ I am a homeowner doing all work officers hav4 exercised their 11.E] Plumbing repairs or additions
myself. o workers' comp. right of exemption per MGL
Y P 12.❑ Roof repairs
insurance required.] t c. 152, §1(4� and we have no 13.❑ Other
employees. r�qo workers'
comp. insura�ce required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners who submit this affidavit indicating they are doing all work and ftn 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 workgrs'comp.policy number.
11
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: pgvnJl,c C1Cir__r �h(y1Y4YlC� �U�(Xin`j
Policy#or Self-ins.Lic. #:(�)C0 D I t0 ( Expiration Date: I 'aUI o
Job Site Address:II (2,c&-)Jo n P -Cer City/State/Zip: EL�" M 4
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 MGLi 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 civic 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 under the pains and penalties ofperjury that the information provided above is true and correct.
Signatur : rl ��cl)�i�t 2 Date 01-02- LO1 (0
Phone#:
Official use only. Do 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 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS '✓�+,
212 Main Street • Municipal Building
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he/she resides or intends 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 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 i
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
1, 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.
Date
Address of work location
City oNorthampton Northton 212 Main Street, Northampton, MA 01060
p
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: $ Cq�, l(Gr e -Cr h �jren(j
The debris will be transported by:
The debris will be received by: �) P-
Building permit number:
Name of Permit Applicant IQ r'Z
dL"G�L-Zee(,
Date Signature of Permit Applicant