17C-177 (9) 29 PLYMOUTH AVE BP-2016-1036
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc : 17C- 177 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit# BP-2016-1036
Project# JS-2016-001755
Est. Cost: $4500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group: MATTHEW WEST 078279
Lot Size(sq. ft.): 4791.60 Owner. WALLACE WILLIAM J
Zoning: URB(100)/ Applicant: MATTHEW WEST
AT. 29 PLYMOUTH AVE
Applicant Address: Phone: Insurance:
P 0 BOX 235 (413) 588-4231
CONWAYMA01341 ISSUED ON.212512016 0:00:00
TO PERFORM THE FOLLOWING WORK.CONSTRUCT REAR DECK
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
tJnderground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Filial: 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 2/25/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Ok-
File#BP-2016-1036 J
APPLICANT/CONTACT PERSON MATTHEW WEST Maw MAMA-)
ADDRESS/PHONE P 0 BOX 235 CONWAYO 1341 (413)588-4231
PROPERTY LOCATION 29 PLYMOUTH AVE
MAP 17C PARCEL 177 001 ZONE URB000)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid M2!2
Buildin Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT REAR DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
fl_qMng Plans Included:
Owner/Statement or License 078279
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOWMATION PRESENTED:
proved 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
-UCM
m
m LV1071
Sig"�' ure&f1luitini- ficial 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.
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pion, MA 01060TwSefs'4 StructnFal { 3
phone 413-587-1240 Fax 413-587-1272 P1olS,te Puns"
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APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
-'- ==-=_ = This secfion tp be campleduby
_ _ =
1.1 Property Address: � �
201 f'yw"Vik., 6v
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IGt
�.�.:-ate _ -- __ - ._ mss....••�,:•,
SECTION 2. PROPERTY'CWNERSHIPIAUTHORIZEDAGENT"
2.1 Owner of Record: r
Name Currc-nt Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name Tint) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED 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) 8;-6>42 ,p-p Check Number
This Secfion For OfficiaC t)se Oni
BuildingPermit Number: Dane :
Issued: .
Signature:
Building Commissiorerlinspector,`of 6uildin95..`:. Date
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 �' I ` ��— 7 I
Frontage
Setbacks Front F,7'( l
'
Side L:_ Y—I R,s_ � L:= R:p_ - r t
(_a
Rear
6 �
Building Height , •( Zb
Bldg.Square Footage1�.►s�� %
Open Space Footage
(Lot area minus bldg&paved r + !
parking)
#of Parking Spaces i
Fill: I`
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:)
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book Page; and/or Document#!
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NOW)
IF YES, describe size, type and location: f
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and location: j
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 O NO I
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
i
i is
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New Rause ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ED
Or Doors Cl
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [® Siding [0] Other[CO]
Brief Description of Prop9seq { 'd t 1
Work: !A-�, Otf3� � 7' ,
Alteration of existing bedroom Yes_ No Adding new bedroom Yes �_No
Attached Narrative Renovating unfinished basement Yes +�No
Plans Attached Roll -Sheet X
sa, !f New House°and oradtllfion.to'existing.housing, cornpfefe the.fotlouvinc_
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
L 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'
as Owner of the subject
property !i
hereby authorize
to act half, in all ma rs I work authorized by this building permit application.
21Z) Zo l,i
Sin ure 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 Name �� z Zl
Sign ture of Owner/Agent Da e
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Tlicablep £Name of License Holder: VJ h C� W�i� -1g T-
Number
D1-2, I 61 I off ' 2.01$
Add ess Expiration bate
Signature Telephone
9 Regis.fered`.Home lmproveinent.Coritractor-_;��L� Not Applicable £
s-s-
Company Name Registration Number
Address Expira ion ate
M, 09 3HI Telephone%3596'42-3
SECTION 10-WORKERS.'.COMPENSATION INSURANCE AFFIDAVIT(IVI.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 building permit.
Signed Affidavit AttacheYes....... £ No...... £
11 $ome 4wner...Egept><on
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 Commonwealth ofMassachusetts
Department of Industrial Accidents
- - Office of Investigations
F 600 Washington,Street
.Boston,MA 0211.1
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): t 4k W ft_l
Address: z?i
City/State/Zip: r c)13 K( Phone #:
Are you an employer? Check the appropriate bog: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and I
❑
employees (full and/or part-time).* have hired the sub-contractors 6. 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 F-1 Building addition
- [No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are�a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12,7 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.® Other p e G�l--
comp. insurance 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 then 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 workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
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 WORD 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 DLA for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Signature:
i� + — Date:
Phone#: ( � �/23 I
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#:
- Citi 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
Fhres
f Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
n supervisor. The state defines "Homeowner"as, " Person(s) who owns a parcel on which
des or intends to be, a one or two family dwelling, attached or detached structures
o such use and/or farm structures. A person who constructs more than one home in a two-
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 buildinq 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
I, understand the above.
(Home owner/resident's signature requesting exemption)
will call to schedule all required building inspections necessary for the building permit issued to me.
)ate
address of work location
c
i
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: � �4t h psv�.— Flor crlc O'e, oro �Z
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant �`�•C4
Z 17-t Zell P
Date Signature of Permit Applicant
I
2°1 r,'-I r h tt
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City of Northampton
Building Department
Plan Review
212 Main Street
Northampton, MA 01060
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REFERENCE PLAN:
OF FAIRVIEW BARpATED
ETT AND O'BRIEN
PLAN AUG. 4. 1902 0NORTHAMPTON, MASS.", , CIVIL ENGINEER. 14- w 2 112 STY
By M.D. PATTESON, N/F
PREPARED E COUNTY HOUSE
) IN THE HAMPSHIR AGES V (') I - �Q :4- ROBERT C. DURKEE
PLAN RECORDED IN BOOK 561, P 0 IN/F t4 z . N & MARY A. pAGEE3�
y OF DEEDS, cd 'L CEREGISTR 'AM j. L _ Z p BOOK 1393
110 & 111. 142 N
Lli 600K 5328 PAUt
D
z AREA=4983 S-F-+
Lij el 100.00'
> N84'45'16"W
N/F N/F
DEN FRANCIS SIENKIEWICZ
MARK A. GLID
& SUSAN B. GL IDDEN & CONSTANCE R. PAGEI54ICZ
BOOK 3831 , PAGE 149 BOOK 5370
4 1 0 60 80 FEET
0 20
20
m 9:: METERS
Ns NESP�oPSTREETSES10 zuREPORT THAT THIS PLAN SHO' AND WAYS 0
AND THE 10
EXISTING OWNERSHIP'S WAYS ALREADY
F PUBLIC OR NE
VATE ,SHOWN ARE THOSE 0 NETHAT 0 N W LIS FOR THE DIVISION
ESTABLISHED AND ) OR NEW WAYS ARE SHOWN, ND
OF EXISTING OWNERSHIPS, FORMS RACTICE
REPORT THAT THIS PLAN CONOF LATECHNICALND SURVEYING
PROCEDURAL �NWEALTHOFOMASSACHUSTTS; IN CONFORMITYIN THE COMMI REPORT THAT THISPLAN HAS BEEN PREPARED..-
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