25C-124 (7) 212 BRIDGE ST BP-2016-1327
GI-S--H: COMMOI WEALTH OF MASSACHUSETTS
Map:Block: 25C- 124 !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-2016-1327
Project# JS-2016-002292
Est. Cost: $10000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAY WATSON 079105
Lot Size(sq. 111 7187.40 Owner: SHULMAN NAMOMI A&CHRISTOPHER C TEMPLIN
tonin,,,: URB(102) Applicant: JAY WATSON
AT. 212 BRIDGE ST
Applicant Address: Phone: Insurance:
50 MAPLEWOOD DR (413) 522-7769 O WC
AMHERSTMA01002 ISSUED ON:5/16/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.REPAIR PORCH
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 5/16/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1327
APPLICANT/CONTACT PERSON JAY WATSON
ADDRESS/PHONE 50 MAPLEWOOD DR AMHERST01002(413)522-7769 O
PROPERTY LOCATION 212 BRIDGE ST
MAP 25C PARCEL 124 001 ZONE URBO02)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REPAIR PORCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 079105
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
llNFOAMATION 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
Si ure of Buildin 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.
9mg vi=n
Department use only
City of Northampton Status of Permit:
2 2016 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
FPT OF BUILDING INSPECTIONS Room 100 Water/Well Availability
NORTHAMPTON MA DIOW Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
S Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
NA54% Z 1L g11)e,Q :T -
Name(Print) Current Mailing Address:
��_ ',Telephone
Signature
2.2 Authorized Agent C
J R y w ,-r r s — •, nn !3 i.C w J ,Q M Tt 47K s
Name(Print) Current Mailing Address:
Signature Telephone -
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
complete by permit applicant
1. Building (a)Building Permit Fee
► U C, ,o
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) i o V U Check Number 16
This Section For ficial Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
�,� ,,..
�,
��:� �.o
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
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
ark in
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Fl ndi ever been issued for/on the site?
NO Q DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW (D YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO & DONT KNOW 0 YBS Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 Date Issued:
C. Do any signs exist on the property? YE5 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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading, vation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aDDli ble)
New HouseAddition ReplacementlWindows Alteration(s Roofin
❑ ❑ Or oors E] )g
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding[0] Other[ei
Brief Description of Proposed
Work: It4 A%& x' is t e-
o
Alteration of existing bedroom Yes No Adding now bedroom Yes ✓ No
Attached Narrative Renovating Unfinished basement Yes No
Plans Attached Roll -Sheet
Ga. If New house and or addition to existinsa housinsa, g2malete the Miming:
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.
1. 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, I v`N M t V Vl L-t RA l Qil/l as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters rel t to work authorized by this building permit application.
Signature cV Ow Date
I, ') A I L' '�� � 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.
3 N, J w f`s''s s o-".-
Print Name _
L==E I6 � ��
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable !
Name of License Holder: J A-1 w.a TS C, L 5 1 O S
License Number
L" lVN AfLCwt,n /� .�r.>R )� 1 0 { c. ( a o \ L
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable !
Company Name Registration Numb
S o M a�'� n La �•s , 4 02
Address - Expiration Date
\
A�v.V�2� } M A d i 0 ii Telephone 1 } t✓
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 es....... No...... !
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings ofone(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 hong 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
`N The Commonwealth of Massachusetts
-" Department of IndustrialAccidents
/
E
Office oflnvestigat'ons
1 Congress Street,Su$te 100
' Boston,MA 02114-2017
www.massgov/dia
Workers' Compensation I nsuranoeAffidavit: Builder s/Contractor slElectricians(Plumbers
Applicant Information Please Print I&Obly
Name (Business/Organization/Individual): .4 T' 5 6
Address: A f L t„it L 1D k `�
C ity/State/Zip: n CS V Phone : 5 2- 7
�' c
Are you an employer?Check the appropriate box: 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 attachedsheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. yees and have workerd 9. ❑Building addition
[Noworkerd oomp. insurance nsurance.
required.] 5. /Fei
a corporation and its 10.❑Electrical repairs or additions
q ] officers have exercised their 11. Plumbing repairs or additions
3.❑ I am a homeowner doing all work ❑ g p
self. No workers right of exemption per MGL
myself. [ �• 12.❑ oofrepairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workerd 13. Other Jpor•t,�\ C-0
comp. insurance required.]
Any applicant that checksbox#1 must also fill out the section below shaving their workers'compensation policy inforin dtion.
t Homeowners 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 spb-contractors and state whether or not those entities have
employees. If the sub-contractom have employees,they must providetheir workers'cornp.policy number.
1 am an employer that is providing wurkerd compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of theworkers 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: ��c.M Date: M N-1 t Z, LJ
Phone#: -k)' 2,Z } �- 6
Official use only. Do not write in this area,to be completed by city or Mown 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 IVIGL 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: 2,kZ S g"` s
The debris will be transported by:
The debris will be received by: e s �-��• �'
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant