38d-025 (4) 24 HAMPDEN ST BP-2016-1497
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:38D-025 CITY OF NORTHAMPTON
Lot: -001 PERSONS CON':RACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: GARAGE BUILDING PERMIT
Permit It BP-2016-1497
Project# JS-2016-002557
Est.Cost: $390.00
Fee:$390.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ELEMENTAL CARPENTRY & CONSTRUCTION INC 110800
Lot Size(sc ft.): 6882.48 Owner: SLOt r I KELLY &RUTH VON GOELER
Zoning: URB(I00)/ Applicant: ELEMENTAL CARPENTRY & CONSTRUCTION INC
AT: 24 HAMPDEN ST
Applicant Address: Phone: Insurance:
118 HAWLEY ST (413) 323-8837
NORTHAMPTONMA01060 ISSUED 0N:6//6/2016 0:00:00
TO PERFORM THE FOLLOWING IVORK:BUILD 30 X 26 GARAGE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring U.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: .hmsc# Foundation:
irivewa Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY TI H. CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATION:,.
Certificate of Occupancy signature:
FeeType: Date Paid: Amount:
Building 6/1620160:00:00 kr Ti
212 Main Street,Phonc(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1497 7 tj
APPLICANT/CONTACT PERSON ELEMENTAL CARPENTRY&CONSTRUCTION INC IJICL✓
ADDRESS/PHONE 118 HAWLEY ST NORTHAMPTON (413)323-8837 Flies(
PROPERTY LOCATION 24 HAMPDEN ST
MAP 38D PARCEL 025 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED Oing.T ,y�
Fee Paid CICU c�+ 6 / T /U
Building Permit Filled out `IIeS
Feee Paid
TymeofConstruction: BUILD 30 X 26 GARAGE A /
New Construction I7y( _GARAGE .„
Non Structural interior renovations
Addition to Existing,
Accessory Structure
Building Plans Included:
Owner/Statement or License 110800
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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
"'ray
Signature of Building O'icial 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
City of Northampton Status of Permit:
JUN 5 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/SepticAvalability
DEPT n o•-,viml=cnon9 ROOM 100 WateriWeil Availability
ece..r:arres.rxn olrm 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:
h'/ This section to be completed by office
c2`/ mpdtm S/' Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
lav Zit Zit I.on 60 der 02Y IAnpse-Anodeivitico.,pfa-, r14
Name( Ant) Current Mailing Address: y _ a /—33 y
. Telephone
Signature
2.2 Authorized Agent:
�
Jun/3 � skocca,E /23- 6c/d ,Sf- &/ch/ v. ,ria ai. ',z
Na e(Print) Current Mailing Address:
f v/.3- sty - a)i
nature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to he Official Use Only
completed by permit applicant
1. Building &,S- ao0 as (a) Building Permit Fee
2. Electrical / o U o .Oa @;Estimated Total Cost of
Construction from(6)
3. PlumbingBuilding Permit Fee
c�r0 . pV i2
4. Mechanical(HVAC) 6r roe. 00
5. Fire Protection -
6. Total=(i +2+3 +4+5) O� o-' _ Check Number A!Si
This Section For Official Use Only
Building Permit Number Date
— issued-
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING AU Information Must Be Completed, Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This calwnn to be IdUej n by
Building Department
Lot Size I`(tr)`S.J . `../`j f'L Itri cXM /-P'"
Frontage oo
Setbacks Front
Side L R' L: 6 R. 4,0
.
Rear .. 70•...
Building Height -/a- —_
Bldg.Square Footage °rbpp.
Open Space Footage ._.. % J
(Lot area minus bldg&pared _.. /Z,
S of Parking Spaces b'
Fill _ . ... __.
(soiling Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds? /'�
NO ® DONT KNOW 0 YES U
IF YES: enter Book Page and/or Document ft
B, Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW O YES d
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained O , Date Issued:
C. Do any signs exist on the property? YES ® 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 4
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 0
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 D Replacement Windows Alteration(s) n Roofing ❑
Or Doors C
ccw�tt
Accessory Bldg. +L.^+ Demolition ❑ New Signs [01 Decks (p Siding[CI Other(01
Brief Description of Proposed (?
Work'. /ter-r ,� �Gy 30 )L Z 6 6-
4,4 5,
Alteration of existing bedroom Yes V/No Adding new bedroom Yes M-7-No
Attached Narrative Renovating unfinished basement Yes V No
Plans Attached Roll -Sheet
Ga. If New house and or addition to existing housing, complete the following:
a. Use of building:One Family Two Family Other czalatc_
b Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? Sf rt
4 i
O. Proposed Square footage of new construction. 3OO Dimensions ab 13D
e. Number of stories? rvm�1
f. Method of heating? l2 r r W,Q Ir # Fireplaces or Woodstoves Number of each__,,,,_
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction UL ;MI 2/10 ?ZAP ftcs
i. Is construction within 100 ft. of wetlands? Yes t/ No. Is construction within 100 yr. floodplain Yes ✓ No
i. Depth of basement or cellar floor below finished grade_/Cn ex
k. Will building conform to the Building andndZoning regulations? ✓ Yes No.
I. Septic Tank_ City Sewer rl' Private well City water Supply /
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I Ke/lyi S. 94 , as Owner of the subject
property f /
hereby authorize �„J-'T"gn1 eS I- +tab4,, rigs4
to act on m behalf, in all matters relative to work authorized by this building permit application.
A line /s% 6
signature of a f I 5 Date
I JAdISJ *'GS Gip d,.at 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.
JG2nes JJa.5 hit L ak
Print Na e
SiWe of Owner/Agent Date
•
SECTION 6•CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �// ) Non6 ,5Applicable £ 2 _
Name of License Holder' liq/na0 tsIra N.fck
— - Dc3/ 33
License Number
/Ls bo /2 Sf" Se-kilt{ 44./A1
„lar ofoap- [ j
Add”"ss Evpir Date
i/i..r' lei ....... V3 - ,53y-O31- -
ts.bature Telephone
J
9.Registered Home Improvement Contractor: Not Applicable f
1390 . .
Company Name / tt /� 1 Registration Number
C/PsClAICd tLirptn/r•/ f tL+ASiiin'11;hi J �jj(( e
Address 11rr / Expiration Dbte
I/8 f AA,' Ji Nat144,144 _Telephone //5 37 / 03
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
11. -Home Owner Exemption
The current exemption for` omeowners"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 1083.5.1,
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,von 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
1� ire t;ommonweattn of/Ylassachusetts
M Department oflndustrial Accidents
•
S _,,JAI.-a Office oflnvestigations
Ectrat—_a 600 Washington Street
rr.41 Boston,MA 02111
-IRO i'v www.mass govidia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information r / Please Print Legibly
Name(Business/Orga�n�izatiomLfindividual): tlrt'7d:t7.31 Cc,'9447 't ICn51,-3.f
Address: 118 ,k;.41e.,
City/StatelZip:ftlO4ia,» rn MA a+(tip o Phone#: 113 - 31?-03l?$
Are yr an employer? Check the appropriate box: Type of project(required):
1.ZI am a employer with 7 4. 0 I am a general contractor and I
employees(full and/or part-time). have hired the sub-contractors
�,�
6. ❑ New construction
2.D I am a sole proprietor or partner- listed on the attached sheet. 7. t?.�Remodehng
ship and have no employees These sub-contractors have 8. R'pemolition
working for me in anycapacity. employees and have workers'
- g P tl' t
9. p Building addition
[No workers' comp. insurance comp. insurance.
required] 5. D We are a corporation and its 10.11:1 Electrical repairs or additions
3.E I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGI. 120 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.] _
'Any applicant that checks box#1 must also Sll out the section below showing their workers'compensation policy information.
iHo 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''camp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. r_ T' COnsurance Company Name: f Ic cit (e 15 5 4 53rzrles> C •
Policy#or Self-ins.Lie.#:U/3 02C& % 5/`frj Expiation Date
eljt/6— /
lob Site Address: / / /i 555c 5J.,f Si 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.
fy
I do hereby c under the paland penalties of perjury that the information provided above is true and con-ed.
Simatur . l� I' Date: 6/IZ/t'r
Phone#' it 13 - 3?}' "0317
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: 02Y gimp Jin St /t%nL,p
The debris will be transported by: Am At
The debris will be received by: a, fie," Rec
Building permit number:
Name of Permit Applicant JRm,s 7 4sbboh-c/
Date ignature of Permit Applicant