18D-021 (2) 19 PINE BROOK CURVE BP-2016-1008
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18D-021 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGLc.142A)
Category: INSULATION BrUILDIN, G PERMIT.
Permit# BP-2016-1008
Project 4 JS-2016-001704
Est. Cost: $2500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group: IDEAL HOME IMPROVEMENT INC 091207
Lot Size(sq. ft.): 16988.40 Owner: LATOUR DANIEL E&MICHELLE R
Zoning: URB(100)/ Applicant: IDEAL HQME IMPROVEMENT INC
AT. 19 PINE QROQK CURVE
Applicant Address: Phone: Insurance:
142 BOYLE RD (413) 863-2128 WC
GILLMA01354 ISSUED ON.-211612016 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION
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 2/16/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1008
APPLICANT/CONTACT PERSON IDEAL HOME IMPROVEMENT INC
ADDRESS/PHONE 142 BOYLE RD GILL01354(413)863-2128
PROPERTY LOCATION 19 PINE BROOK CURVE
MAP 18D PARCEL 021 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out dL
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 091207
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I131�iATION PRESENTED:
4�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
De )if y
.� �e — "
Sig 4 a kero—fru-I eing ficial Date Q
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'iof 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.
i
I
Department use only ,
City of Northampton Status of Permit
RECEIVED Building Department Curb,Cut/DrtvewayPermlt-•
212 Main Street SewegSepticAvallabllity
112Room 100 Water/V1/ell Availability j
Northampton, MA 01060 Two Sets of$t',rUctural Plans
one 413-587-1240 Fax 413-587-1272 Plot/Site Plans r
DErT OF BU!LC;NG INSPECTI N
NORIIiAMFMN,MA 01060 Other SpeClfy:
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 PropertV Address: This section to be completed by office
A (bvooC (.,L�y'V Map Lot Unit
Cone Overlay District
r�Im St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name Print Current Mailing AddresAs: i z,✓ 'Z o
L'� r Telephone Li 1 �
Sig ure
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Si na r Telephone
SECTION 3-E STIM A TED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed b 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)
c� Check Number b
This Section For Official Use Only
Building Permit Number. Data
Issutgd:
Signature:
Building Commissioner/Inspector of Buildings Date
f, S !• a�i4ttssttcf)usetta �{ `;;,;
1• DEPARTMENT OF BUILDING INSPE,CTIONS A"
212 Main SLreeL . Municipal Building
Northampton, MA 01060
LOUISHASBROUCK BUILDING PERMIT FEES Phone: (413)587-1240
BUILDING COMMISSIONER Effective July 21, 2008 Fax: (413)587-1272
DEMOLITION $ 20.00 ACCESSORY STRUCTURE
$ 35.00 PRINCIPAL BUILDING—Residential
$200.00 PRINCIPAL BUILDING-Commercial
*NEW CONSTRUCTION $ .50 per square foot for 15`floor
.30 " 2"d floor
.20 floors,attic,basement,garage
STRUCTURAL ALTERATIONS IN ALL USE GROUPS
$6.00 per thousand dollars of estimated cost or fraction thereof,
with a minimum fee of$55.00
$25.00 WOODBURNING STOVE
*NEW ACCESSORY STRUCTURES one hundred twenty(120)square feet and over
$ .20 per square foot with a minimum fee of$25.00
*NEW ACCESSORY STRUCTURES under one hundred twenty(120)square feet
$25.00 per inspection
*SWIMMING POOLS $30.00 for above ground
$60.00 for in-ground
*SIGNS&AWNINGS $30.00
*DECKS $50.00
REPLACEMENT WINDOWS $35.00 a
SIDING&ROOFING
Residential $35.00 per structure
Commercial $55.00 min.per structure OR$61K of estimated cost
TENTS $25.00
*ZONING REQUEST FORMS $15.00 (includes home occupation registration)
REISSUE OF LOST PERMIT $25.00
CERTIFICATE OF ANNUAL INSP. $100.00 (minimum)
Temporary Certificate of Occupancy $25.00
PERMITS REQUIRING ONLY 1(1)INSPECTION WILL BE A MINIMUM OF$25.00;ALL OTHERS WILL
HAVE A$50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE City of Northampton
AND SUBMITTED,WITH THE COMPLETED PERMIT APPLICATION,TO THE OFFICE OF THE BUILDING
INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL FEE.
11 NO CASH -CHECKS OR MONEY ORDERS ONLY 1!
*Filing deadline is 12:00 pm(noon)on Wednesday.
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
Building Height
Bldg. Square Footage %
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 0 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 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 Q NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excavaUon,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 applicablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) F__J Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [0] Other
Brief Description of Proposed
Work: C � '�" t'S ,7L L..t-9 \,�� ',�,E 1 i(1 6��L,1�Ci t I C.' co, I n o
Alteration of existing bedroom Yes / No Adding new bedroom Yes -- No
Attached Narrative Renovating unfinished basement Yes --'No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing 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. 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, CG�l►'1 1,� �11 - as Owner of the subject
property
hereby authorize
to act o my behalf, in afters relative to work authorized by this buildin permit application.
tl S m
Signat 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.
Signature Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ii Not Applicable ❑
Name of License Holder: � l ' I
License Number
I �1
1Z(A C�III I L •I �L;1 �c
Address 7 Expiration Date
Si ature Telephone
9.Reaistered Home Improvement Contractor: Not Applicable ❑
I C 1. tti I ►�� �Z�,Lid u,r 1 f 1 L (114
Company Name Registration Number
� �
Addres>; Expiration Date
f
h . 22
Telephonei6`I�1.I J'
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 buildin ermit.
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.$.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,an 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 cal Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
=� Boston,MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le0bly
Name (Business/Organization/Individual):
Address: �'��,� I �� ca
City/State/Zip: 0 �}" pL 3 � Phone
Are yo ly,an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. E]New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. Buildingaddition
[No workers' comp. insurance comp. insurance.:
❑
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 1 l.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.[ ther S `�
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors 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 workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. i
Insurance Company Name: ._4 ckal
Policy#or Self-ins. Lic. #: L Expiration Date.
Job Site Address: IL G , ) U1_(_ City/State/Zip: k1 ��
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 MGL 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 civil 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 hereb fyatt&r the pai and penalties of perjury that the information provided above is true and correct
a'
Si ature: �ti,L- Date: bob
Phone#: 25
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 212 Main Street, Northampton, MA 01060
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: " '-V�� V c,(�V--
The debris will be transported by: t1 I R
The debris will be received by: nj
Building permit number:
Name of Permit Applicant u� I S
Date Signature of Permit Applicant
Property Address: �'� 1,9�ru— by, LQ iL
Contractor
Name:
Address: �c: IjC�j ►2(�
City, State:
Phone:
Property Owner �—
Name:
Address:
City, State: j"� ;f Cry o-v 1"1
(contractor) attest and affirm that the building I intend
to insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and
that I have provided the property owner with a copy of this affidavit.
Contractor signature
Date