29-578 175 OVERLOOK DR BP-2016-1197
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-578 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-1197
Project# JS-2016-002059
Est. Cost: $3800.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN MICHONSKI 49376
Lot Size(sq. ft.): 20778.12 Owner: FITZGERALD ALICE F&HAROLD R FITZGERALD JR
Zoning: Applicant: JOHN MICHONSKI
AT. 175 OVERLOOK DR
Applicant Address: Phone: Insurance:
66 CONWAY ST (413) 834-7725 WC
SHELBURNE FALLSMA01370ISSUED ON:4/13/2016 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 4/13/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1197
APPLICANT/CONTACT PERSON JOHN MICHONSKI
ADDRESS/PHONE 66 CONWAY ST SHELBURNE FALLS01370(413) 834-7725
PROPERTY LOCATION 175 OVERLOOK DR
MAP 29 PARCEL 578 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid , o
V to
Building Permit Filled out
Fee Paid
Typeof Construction:_INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 49376
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO$MATION PRESENTED:
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
Drjnqlition Delay
Si re of Bui di Oficial 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.
Department use only
of Northampton Status of Permit
Y _$u'I ing Department Curb Cut/Dnveway Permit
Ii 21 Main Street Sewer/8epticAvailebilify
i oom 100 Water/Well Avalabtlity
ppR 3 X016 i
No ha MA 01060 Two Sets of Structural Plans r
phgne_4-13- 87-1240 Fax 413-587-1272
r
i r Y
Y
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map Lot Unit
`Orem ww Zone Overlay District
Elm St.District CB District
SECTION 2,-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
\4\: C @- " �' x w 1[ �7 S �Y�cS�m� DT ��asty►t t %AnA.
Name(Print) Cu ent Mailing Address:
_ t%.,. — y) 3
Telephone
Signature
2.2 Authorized Agent: L '!
yd v cs S './LVt _.��(4s wl�
Name(Print) Current Mailing Address: 01 3 O
nature Telephone
SECTION 3!m ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building , 0 (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=0 +2+3+4+5) 31T00. Ca Check Number 15-12 ta
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Ttay,. gifj--af MD"rti�iXll� ltOTi s
�414ttgguc4u.5ettg
DEPARTMENT OF BUILDlNC, lNSPEC'TIONS
212 Main SLreet Municipal Building r _
NorthampLon, MA 01060
USHASBRLOOUCK 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 1'f floor
.30 " " 2"d floor
.20 " Yz 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
SIDING&ROOFING
Residential $35.00 per structure
Commercial $55.00 min.per structure OR$6/K 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$50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE City of Northampton
AND SUBMITTED,WITH THE COMPLETED PERMIT APPLICATION,TO THE OFFICE OF THE BUILDING
INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL FEE.
It NO CASH -CHECKS OR MONEY ORDERS ONLY II
*Filing deadline is 12:00 pm(noon)on Wednesday.
t
The Commonwealth of Massachusetts
1 Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR, MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
ss ection For Official Use Only.:`
17afeApplied:
Building Official
_ •r. .
:Signature Date'
:.:...
: . :�..:.:.'. : .. t. ,:':. ;;...•._,. r:, .':.. ECTION 1:SITE INFORMATION;'::
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
Wily)Oby-
1.1
k1.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M,G.L c.44,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
".SECTION 2 PROPERTY OAR
2.1 Owners of Record:
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: 10 OF I?I20POSEI)WORKZ(check.all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
BriefDescription ofProposed Work: 4wJQ r4fF i ;� �,_ qq WIC
Mh
SECTION 4:.ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use t3iiI
(Labor and Materials) y
1.Building S �, so L Building Permit Fee:$ . Indicate how fee is determined:
2.Electrical $ ❑standard Cita/Town Application Fee
40
_::
❑Total Protect Cost'(It6mri'6)xmultiplier x
3.Plumbing $ 2. Othex Fees: $
4.Mechanical (HVAC) S List:
5.Mechanical (Fire $
Su pression) 'Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost. $ �j2� 00` ❑Paid in Full 0 Outstanding Balance Due:
r SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Y3 74
License Number Expiration Date
Name of CSL Hold ons Home Rep,4 Service
John Michonski List CSL Type(see below)66 CnQ
V
Na.and Street ..Description
ShE`lbLt7rif Falls,MA 01370 U Unrestricted(Buildings u to 35,000 cu.tL)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC . Roofing Covering
WS Window and Siding
q, -7-1 Y7 7 6..5 SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIc)
D 11
John's Hnm#- MC Registration Number Expiration Date
HIC Comp C, tM* gki
No.and Stre Shelbume Falls Email a ess
,1�r4 C13r"�
City/Town,State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATIONINSUR.A,.NCE 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 building permit.
Signed Affidavit Attached? Yes..........®. No........:..0
SECTION 7a:O'ER AUTHORIZATION TO BE COMPLETED WHEN.
OWNER'S AGENT OR CONTRACTOR APFLIES FOR BUILDING PERMIT .
I,as Owner of the subject property,hereby authorize ;�p t� W 1 t �„�„a,�•
to act on my behalf,in all matters relative to work authorized by this building permit application..
'e�>��
PrintOwner's Name(Electro afore) rDate
SECTION 7b:OWNERr OR AUTHORIZED AGENT DECLARATION..
By entering my name below,I hereby attest under the pains and penalties ofperjury that all of the information
contained in this application is.true and accurate to the best of my knowledge and understanding.
,-216A V4%6L%pAA
Print Owner's or Authorized Agent's e(Electronic Signature) Date
NOTES:
1. AnOwner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fiord under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.izov/oca Information on the Construction Supervisor License can be found at www.mass.goy/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of haMaths
Type ofheating system Number of decks/porches
Type of cooling system .Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: FA Cf Y 376
' Repair 3erviceLicense Number
John Michonski
Conwayffi St. 9-1f- aelb
Ad ss -:.., Shelburne Fails,MA 01370 Expiration Date
v/ 3-va
S' n ure Telephone
9.Realstered Home Improvement Contractor: Not Applicable ❑
ya?a g
Company Name Registration Number
1-1-0 John Michonski
66 ConwaySt. -I -01 W4.
Address ,,.-__, Shelburne Falls,MA 1370 Expiration Date
Telephone y)3-173Y 77ds
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 building permit.
Signed Affidavit Attached Yes....... +4h 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
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: % '75 dv.&
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant Jo\,�s �A
Date Signature of Permit Applicant
�b d�.�c• s o,,. �*s ,,ob.
City of Northampton
Massachusetts
A
MPARTN=T OF BUXLDXZq(i xxsrzC!rj0xS
212 Main Street a Municipal Building
Northampton, MA 01060
Property Address: ) 75 Qv-rl=k.
Contractor
Name: F,
Adlkj— inha's Hi-)m*- gg-pair Sgp4c;g
John Michonski
Address: Lk�"" 66 Conway St.
;,,ft� Shelburne Falls, NIA G1370
City, State:
Phone: `//3.19 a Gas
Property Owner
Name: C,-e - -7g,-4_-r,%
I-j
Address: 1 ,7 5, C)V--r 100 k Qr:y
City, State: Q
(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
y-7-80/-6
The Comrtonwealth of Massachusen s
D3eparhwnt of IndusVid Aedes
Offxe o fInves4adons
640 Washinx wn Sired
Boston,?plass. 02111
w-*w.rnas&gov/dia
Workers' Compensation Insurance Affidavit: $udders/Contractors/Electrieians/Phtm.bers
Applicant Information Please Frim LeOW
Name(Busa—mlor izzdea3lladi-vidcal):JOHN'S NOME REPAIR SERVICE
Address: 66 Conway Street
CitylStatelZip: Shelburne Fads Ma. 01370 Phone#: 413-834-7725
i Are you an employer?Check:the appropriate box: Type of project(rdgvh—ed): 3
. 3323 as employer with 3' A 4.0 i am agamaj ow�i and I 6.Q\ear consuuction j
a employees(M an&?or part time j.* have hired the sub-c�is t ?,CE Remotl<1sxa
a
proprietor partner- listed on the attached sham
2.O I am a sole proprieto }
working
and have
Rasz4femploy ces These SW>-cx�� '����ors bave�f j 8�.rl Demolitio,�nj��M
j TT�g fz me in Qi, i-ty �yV4J ,�.�'{,Ve w rs' 3 .� 7.Cl Building�iLLkt:tz:.'
t}tali #S'comp.i CE comp.mnuanice.`a j i
}
rtelttrred] 5 Owe are acorporation and its 10.ri Electrical res or additicas
i
3•(;l am a homemmer doing all work ofieas leave exer=sed their I2.0 Plumbing retr3iis of additions j
myself I-No workers'comp. right of a xcaption pin MGL
( bice requ r d]t c.252,$1(4),arta we have no 12.❑Roof repairs i
employees. Ino 1%,orkers, ? I3.0Other Wea ftftatiO�l I
Comp.instn ance ieq-mred.l 3
*Aay sppUm t tw&d=U box NF1 est she OR ea 6e net£ea beim 600W a mon pocky bdbnWalm
tHoa Nowurs who nbaa#*&sffidx*t>ti eg Mare a0b3g ag-ori;scut[dee arise ouW& s most nbata nw sl6darrt bacawg=c1L
ecaan&Uebe&*b bo%>$afa ad**as ewbothwornotdmmeaftabxveemplovem U
!!ic have = tdrW*rb ss'magetcyanobw
I atm an exnpieyer that is prvrdal*workers'em pmsad m h=mvzcefir mV m#,aysm Below is thepo&y=djob s#e
�; :Guard Insurance Group (NQrguard Ins. Co.)
Policy=or self-ins,Lic.=•JOWC 6(aa cf q 1 ? expiration Date: aOl to
Job site Address: 173` Qv L-1fM)L 'W- l
Attach a copy of the workers'compensation polars declaration page(showing the policy number and expiration(date).
Failure to secure coverage as required under Section Zia of N-40L 152 can?east;to the imposition of criminal penalties of a zine
UP to$1,500.00 andFor one year m4 ec:nme nr as well as civi pe naldes in the form of a STOP WORK ORDER and a fine of
$250.00 a day against violator.Be a&ised that a copy of this statement maybe fbmwded to the Office of lzve:sdgatiors of the
DIA.for coverage verification.
I do herby scnc3er the pabu and p�of perjury that the tnfornudon p?ovided above is true and correct.
Si e .cam: Y-7-a a
C111 -
Prvu atrse:Johns Michonski Phone-:413-834-7725
3 qo%d rt use only Do not write in this area to be con plded by city or town qfi7cial
i
( City or Town: PeraB=itfiicense
Issuing Authority(drele one):
E IJMsrd of Heath 2. MdtU Ikparttaent I CityTown.Clerk: 4,Electrical Inspector S,Plumbing Inspector
6.Other
Contact Phont T• i