10D-017 (4) 7tS"I' BP-2002-0317
GIs#. COMMONWEALTH OF MASSACHUSETTS
Mai ffI6ck'Ion-017 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: she BUILDING PERMIT
Permit# BP-2002-0317
Proiect# JS-2002-0485
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 40772.1 6 Owner: ABM NOMINEE TRUST
Zoning: SI Applicant. RYAN SANDY
AT. 175 MAIN ST
Applicant Address: Phone: Insurance:
182 MAIN ST (413) 587-0406 (�
LEEDSMA01053 ISSUED ON.91241010:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 31 X 8 STORAGE TRAILER
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/24/01 0:00 00 1143 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2002-0317
APPLICANT/CONTACT PERSON RYAN SANDY
ADDRESS/PHONE 182 MAIN ST (413)587-0406 Q
PROPERTY LOCATION 175 MAIN ST
MAP l OD PARCEL 017 001 ZONE SI
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
ineof Construction: ERECT 11 X 8 STORAGE TRAILER__
New Construction
Non Structural interior renovations
Addition to Existing
AccessoKy Structure
Buildina Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
1NF_99MATION PRESENTED:
Approved Denied
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan OR Special Permit and Site Plan
Major Project: Site Plan OR _Special Permit and Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §_
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commissi
Signature of Building Official Date
5X
L
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
a
I o thampton Sit tvsAo
i-6 i epartment Cur".bC a ID`rivewayR$ a `
r 21 n Street Sew" rlSep#icA
!!! �} 100 Watei-I 611 Avatlablltty
I SEP 2 d Ol �� ��
Nc
orthatill o , MA 01060Tv�o'Sets of Structvr�l
x x +. ::"# , ,`; y ✓ u`'• "ate ,'W
124 Fax 413-587-1272 PlotlSite Plans` -r a�
DEPT OF BUILDING INSPECTIONS Other Specfy3 � � '"' f�
NORTHAMPTON.MA 01060
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
r—'
SECTION 1 - SITE INFORMATION
1.1 Property Address: (This section to be completed by office
FIE �{ Map J Y Lot Unit
1 CSS . �c ss cj 10-s � Zone Overlay District'
—� Elm St. District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Recor
lcpry L. a — 17S7 & x"
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
1Ram
N e(Print) Current Mailing Address:
�4 13 7- O-1 LIC
L
Signature Telephone
SECTION.3 -'ES ATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by permit applicant
1. Building (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 = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
i
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF 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: f
Rear
Building Height
Bldg. Square Footage j %
Open Space Footage °/;
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 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 DON'T KNOW
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:
SECTION 5- DESCRIRTIONI'OF PROPOSED WORk'(check aI applicab eY
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new be om Yes No
Attached Narrative o Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
Ea. If New h60' and--or`ziddition'to existing housing, comp ete,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. Dimensions
e. Number of stories?
f. Method of heating? _ Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. _ Mascheck 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
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 COMPLETEDWHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject prope
hereby authorize to ac
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 a e
Signature of Owner/Agent Date
SECTIONt CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
i9 Reglstered'Horrie lmpiovement Co"ntracfor ,g,,, Not A p p Iicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(MG..L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affid,
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
1: �IomeDwnd it p, n.
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familic
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner act>
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(
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, S te'aid Local Zoning Laws tate o assachusetts General Laws Annotated.
Homeowner Signature
CIiAMP .
8 fl Gx� ;rlr II> (J�i111�1 III1
�[JEaC{�tib[ltS
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal BuiUng 'o
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AFFMAVIT
I,
(Ii ce nser/perms t lee)
with a principal places of business/residence at-.
—__ - (pllone )
(stMcucityk;atrhip)
do hereby certif),, under the pains and penalties of perjury, that:
O I am an employer providing the following worker's compensa,;on coverage for my
employees working on this job-.
— — (Ing, cin Company) (Policy Number) (Expiration Date)
( ) Iarn 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 Conn-actor) (Insurance Company/Policy Numbcr) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurana', Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(artadr ad'--` ol to ixlude infonzssiioa pexYaining w e11 ccdzndo:s)
O I aIn a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plcasc be aware that wfvlc homcowncrz who employ Pons to do maiatcn=ce,cm�ucioo or repair"uric on a dwelling of
not mock than or"units in NvEncf,the homoosvncr rc=dca or oa the grounds appurter tioi thc�c erc oot Gala-.1y co(mdu-cd to be
cmployrra under the%vOrkez's ce¢tpcnsalica Act(GL152,s31(5)),application by a homcowacr for a Uccw,:cc permd may evident the
les2l etatue of an employoc under the Workee,Compematian ACL
I understand that a copy of this s atcmmi may bo foQ www ed to tbo Dtpartuscat of Iodu3b iel Aoodcnts'Offioo of lirursnca for the
coverage vcrificalioa and that failure to secure coverago undcr soction 25A of MGL 152 can lead to the imposition of a imus!pcaalt:es
coolish of a frac of up to S 1,500.00-dlor of tip to ora year and civil pcmltics in the focm of a stop Work Ord--and a
film of S 100.00 t day tgniwzt mc.
For des—tsl—only
permit Number
Nfapl Lot n
Signahirc of Lion /Prr,nittm e