10B-082 (4) 73 AUDUBON RD BP-2016-1498
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10B-082 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REMODEL BUILDING PERMIT
Permit II BP-2016-1498
Project 4 JS-2016-002558
Est.Cost: $41000.00
Fee:$266.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DANIEL HATHAWAY 081793
Lot Size(so.n.): 172933.20 Owner: FALES HAL&ELIZABETH SULLIVAN
Zoning: RR(100)/WP(231/ Applicant: DANIEL HATHAWAY
AT: 73 AUDUBON RD
Applicant Address: Phone: Insurance:
2 OLD GOSHEN RD (413) 695-2937 0
W I LLIAMS B U RG MA01096 ISSUED ON::6/16/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.•REPAIR UPGRADE EXISTING DECKS, PORCH
ANDD 60 SQ FT TO EXISTING DECK. REMODEL KITCHEN.
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 St 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 6/16/2016 0:00:00 $266.00
212 Main Street,Phone(413)$87-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1498fritieAk ,u
APPLICANT/CONTACT PERSON DANIEL HATHAWAY ok"
ADDRESS/PHONE 2 OLD GOSHEN RD WILLIAMSBURG (413)695-2937 Q 7 bit
PROPERTY LOCATION 73 AUDUBON RD A.R „if
eo`�
MAP 10B PARCEL 082 001 ZONE RR(I00)/WP(23)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid C.:C $ f90a. '71.1 Et It
Typeof Construction: REPAIR UPGRADE EXISTING DECKS,PORCH ANDD 60 SOFT TO EXISTING
DECK.REMODEL KITCHEN.
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 081793 ,..0 x
3 sets of Plans/Plot Plan �61 V eG r 6if(lC
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
De I 'C.• Delai'�
Si_: g Official 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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City of Northampton Status of Permit
I Building Department Curb Cut/Driveway Perm[
5 212 Main Street Sewer/Septic Availability
Room 100 Water/ Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
DEPT c BURT
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13-587-1240 Fax 413-587-1272noatNuneoe, Apms 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
n xuouo4b4 RO YMap Lot Unit
LQ5 Zone Overlay District
Elm St.District(// CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT /,
2.1 Owner of Record: /(
NAd. 0)(144) 7*, Aug n1 20 beesa5
Name(PrintCurrent Mailin Addr ss:
58b &ego
Telephone
Signature
2.2 Authorized Agent:
Name(Print) 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 31/06° (a)Building Permit Fee
2 Electrical /ODD (b) Estimated Total Cost of
Construction
from(6)
3. Plumbing 20000p BuildingPer
Permit Fee pp1
4. Mechanical(HVAC) cA
5. Fire Protection V �l1
6. Total=(1 +2+3+4+5) 0.1/i, OOO Check Number/87 (2
This Section For Official Use Only
Building Permit e Number IssIssued.Signature:
Building Commissioner/Inspector et Buildings Date
r •
Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
.y erg Building Regan-meat
Size -.. 9/•'! ! RG. .._.Sme
Frontage _ !4O 64
0
Setbacks Front '.151 pa • 7,31 GG/J
Side L R ZgI L R 2.67 _..
Rear _..
Building Height
Bldg.Square Footage %
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces ,
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW YES O
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW (3 YES Q
IF YES: enter Book • Page. and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 44, YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO S
.. .....__....
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, excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Rooting n
Or Doors C
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks 193.. Siding [0] Other*
Brief Description of Proposed noEPinQ UP 4I¢AV To exUJ774 OetkfPa lee 44 trna- (,p.a t
7
Work: Tb G)c/JLi Dreg . £E+NdX-t 191 -E7U !u!� EX Atr FLod,p Pr.,4nJ
Alteration of existing bedroom Yes ii.7 No Adding new bedroom Yes No
Attached Narrati Renovating unfinished basement Yes V No
Plans Attached-Sheet
ea. 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?
C Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
1. 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� li(AGENT+� / OR CONTRACTOR APPLIES FOR BUILDING PERMIT
T I, milF:2 /es as Owner of the subject
properly
hereby authorize baitiel z!4lgi?Alf Z
to act on my behal in all aleters relative to work authorized by t lding permit application.
Date Signature of Owner Date
I, , 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
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Holder: S iL
License Num pe1 r / g 3
z ac o 4a3 v �2wu�i�n azs D
Ad . , - Expiration Dalt
e
C • N/3 b 'S 2939/ //
Signature ` Telephone
9.Registered Home Improvement Contractor. Not Applicable £
alp/ altrAo•r4-w* e LfaJaoladle-eta.
Company Name Registration Number
Z 060 (ins ifiZat GM,.0 s9ac l�169P
Address / Expiration` Date
Cif p
Telephone( Z S 37 / • 6 • to iO
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 uilding permit.
Signed Affidavit Attached Yes. .. E No...... £
11. -Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 Wil1Ue 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(Wprkens' 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 perton(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
•
The Commonwealth of Massachusetts
.., IJepartnaent of Industrial Accidents
.%_
if Office of Investigations
r4
et-7.
600 Washington Street
kk •-x Boston, MA (32111
'i', t/
www.rnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ""'' Please Print Legibly
Name (Business/Organization/Individual): nail)/� I�' Sti At
Address: 2 OLQ 4-65PfCiU hew
City/State/Zip: Atankslf 56u eL Phone#:_q/ ( I s -70 31
Are you 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. ❑ New construction
2.+am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insuranee3
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1111 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
Ilk 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 subcontractors 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.
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 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 ur der the pains and penalties of perjury that the information provided above is true and correct.
Signature: Of— Date: h • I Y• I C.
Phone#: Lf() 445 2,q
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
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{ DEP.1iTPPENT OF BUILDING INSPECTIONS
y-. 212 Main Street a Municipal Building �.
Northampton, MA 01060 d,s j1
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he/she resides or intends 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 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 building 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
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)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
•
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: 73 A'•vnJbbxI 160 1,r:£7J5
The debris will be transported by: met/ 0420 iu st/
The debris will be received by:
Building permit number:
Name of Permit Applicant
Date Sign ure of Permit Applicant
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All dimensions size designations 'This is an original design and must Designed: 5/11/2016
given are subject to verification on not be released or copied unless Printed: 6/14/2016
job site and adjustment to fit job applicable fee has been paid or job
conditions. 2- J.20 order placed.
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