36-264 (6) 199 MAPLE RIDGE RD BP-2017-0047
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36-264 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-2017-0047
Projects JS-2017-000088
Est. Cost:$3500.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
use Grono: Homeowner as Contractor
Lot Size(sq. ft.): 145926.00 Owner: DOURMASHKIN THOMAS&CYNTHIA A
Zoning: Applicant: DOURMASHKIN THOMAS & CYNTHIA A
AT: 199 MAPLE RIDGE RD
Applicant Address: Phone: Insurance:
199 MAPLE RIDGE RD (413) 584-4038 0
F LO R E N C E MA01062 ISSUED ON:7/2 0/2 07 6 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR ROT DAMAGE TO WALL-section of open
wall must be air sealed & insulated
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: Houses 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 7/20/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0047
APPLICANT/CONTACT PERSON DOURMASHKIN THOMAS&CYNTHIA A
ADDRESS/PHONE 199 MAPLE RIDGE RD FLORENCE01062(413)584-4038 O
PROPERTY LOCATION 199 MAPLE RIDGE RD
MAP 36 PARCEL 264 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT ''// {,,*/
Fee Paid 7 2' 4 S
Building Permit Filled out
Fee Paid
Typeof Construction: REPAIR ROT DAMAGE TO WALL I
New Construction I -
Non Structural interior renovations ' C -1 , 6 O A ' ( Jce
Addition to Existing Nun- /
Accessory Structure n- b C® Li, Se,,/P Q
Building Plans Included:
Owned Statement or License cPks,y (q Fe
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN 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
Den e '.'on •-la
Ai
//� _ a0 -7(
Signa re of luilding •'ici. 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.
RRC: -
Deparnentuse c'li}
I City of Northampton State-s orPe mi - _ dI
JUL i 8 L itBuilding Department Cur Cu Drmeway Permit
_ 212 Main Street Serve/5 ptic Availabdl
DEPT.CF enitptNa iusa�criuns Room 100 Vyate- r/W Il Apalabdiy
NOn1NAMMN mwotose Nil MA 010b0 Two Sets of Structural Plans - - I
phone 413-587-1240 Fax 413-S87-i272 PIo ,Si Plan - -
Offer Spec ry
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
I Address 1.1 Property i 91 M4 Q11� (�e �rJ This section to be completed by officePropertyr R d
rf5✓-t-fr4 inM,�t Mep Lot Unit
Zone---2= Overlay Distant -
-
Elm St District-- - - CBDistrict
ISECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
I Mos, L. v Cl,. 4 4 (a4 nil
CCC
k2d�e n �nrewre O(O62
Name( r :g„: k,
Signature GUTe:tMAlIitit/lift/Nedra
Telephone v Y032.1.
.
2.2 Authorized Aoent:
Name(Pont) Durant Maing Aodress:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Doliars)to be Official Use Only
completed by permit aoolicant
1. Building I NQS'p 5� (a) Building Permit Fee
2. Electrical I (b)Estimated Total Cost of
Construction from(B)
3- Plumbing Building Permit Fee
4. Mechanical(HVAC) a(
5 Fire Protection I
/'
6. Total=(1 +2+3 +4+5) ,Check Numbern 40(
616
This Section For Official Use Only
Building Permit Number Date
Issued:
Slcnature:
1 Building Commissioner/Inspector of Buildings Data
Email : /_.ur+tAxk,silvr(i)iaot. roan-
1 Section 4. ZONING I An Informaior Must be Completed.Permit Can 3e Denied Due To Incomplete information '
casing Proposed Required oy Zoning I 4
•
This column m be flied is by
Building Desarrnem
LotSZ.e
Frontagen —
. --
Setbacks Fon. Q__
Side Liiii0 RSD L __ _k
Rear 'sZ E.--...
BUi]ding Height I sa _ _LL
Bldg.Square Footage / _ a
Open
areae Space Footage �y`^�'_
!La zrezn nus Egg/paved •1. 1 • __
o
Feofarking Spaces :- I ..—.
Fill:
A. Has a Special Permit/Variance/Finding ever been issued,�for(/'on the site?
2/
NO Q DONT KNOW Q YES
IF YES, date issued: 07 _
IF YES: Was the permit recorded at the Reg 'try of Deeds?
NO Q DONT KNOW 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 Q
IF YES, has a permit been or need to be obtained from the Conser/ation Commission?
Needs to be obtained Q Obtained Q , Date Issued
C. Do any signs exist on the property? YES Q NO ce
IF YES, describe size, type and Location:
D. Are there any proposed changes to or additions of s:gns intended for the property? YES Q NO 07
IF YES, describe size, type and Location:
E Will the construction activity disturb:deeding,grading ex gag, or filing)over 1 acre or iit pad of common plan
that Viii sturb over 1 acre? YES Q NO
IF YES,then a Northampton Storm Water Management Permit from tse DPW is requited_
t.
SECTION 5-DESCRIPTION OF PROPOSED WORM(check all acolicable)
NewHouse ❑ I Addition In Replacement Windows Alteration(s) n Roofing n
Or Doors C F
Accessory Egg. ❑ Demolibo ❑ New Signs [O] Decks [O Siding 101 Other[DI
PI
Brief Description of Proposed r I
Work. ,.. Ir D rt_ja Lf 91 v It_ T. '
/
Alteration of ezistina bedroom Yes ( No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes V No
Plans Attached Roll -Sheet
6a -If New house and or addition ¢O EXIS¢!RQ flOIP3i:IQ, GOTdPELE the FOI[OW[CId
a. Use of building One Family i 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 farm 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_
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
I, ! Up kr 1n , as Owner of the subject
property A
hereby authohze 6Wrq� 1 1 2✓-
to act on my be in all e ers relative to authorized by this building permit e plication.
Signature of dd her � Date
I, �A/414 [ )oi rywgtz 0 as Owner/Authorized
Agent hereby LLLedare that the s=. ments and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed underthe� ns and penalties of perjury.
l•WniA Doi Dp.,i.(—A / ^
Print Name
'Thins» 1410
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Suaeeiisor: Not Applicable E
Name o'i Linens!Holder:
License Number
Address Expiration Date
Signature Telephone
9 Reaistered Home Improvement Contractor Not Applicable E
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this applicaion.Failure to provide this affidavit will result
in the denial of the issuance of the building permit
Signed Affidavit Attached Yes ... £ No..... E
11; - Home ®weer 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 fami
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 fors 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 an assumes responsibility for compliance with the State Bu lding Code,City of
Northampton Ordinances,State ocal o g Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
The Commonwealth of10P,.S a h Jti.'CieJ3C
-rY--1 ;Depanamel"t ofIhndostr¢t1 Accidents
f' V 0 e oflvnves*'ga*ovcs
_ 00 1'�oohdngton Stdeet
Boston, MA 02111
., ;=- ...
WNW.
0J'orke-s' CompensefnoB Insurance Mildest:: BuThIne s/Contstuatort ectrichans/]Plianasers
Ay,nlieant Information Please Print Legthhliv
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone fr:
Are you an employer? Check the appropriate box: Type of project (required):
I am a employer with 4. I am a general contractor and I
employees (full and/or parttime).* have hired the sub-contractors 6. ❑New consimcdon
listed on the attached sheet. 7. ❑Remodeling
2.❑ I am a sole proprietor or partner-
These sub-contractors have
ship and have no employees 8. ❑Demolition
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance comp. insurance.= 9. ❑Building addition
rie'quire] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL
YP 12.n 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 secdon 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 job site
information.
Insurance Company Name:
Policy# or S elf-ins.Tic. #: 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 cun er f�:aims and pe !ries of perjury that the information provided above is true and correct
•/,Silinande6�% { �y ii;sus MAN . Date: '7/1(D//(0
Phone#: 1 ' J fit l - l o�F
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License k
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 o Northampton
k , 7
stA Disseenhess=the
yc
XEP RPIlT'NT L -D S6 r ONS
IB 212 Main Street
M 219 r w
'—Y Vow __on, ma 0:060 y, .1"
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EYIYIPTION 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 Dour). a vouch 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 ins.ections as required can DELAY the project until such time as the proper permits
and inspec a - lade
I, ar,A.,•4. ( . understand the above.
(Home owner ' idents signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date -Vico/ tip //�
Address of work location fC 1 )((fi�V nn tt It Qi1 PO
elk(ewcit blD6v
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c40, 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: • ' f • 12 9 . , Y1d , Mit
The debris will be transported by: Jur inAti
The debris will be received by: Vajie,1 P4,tbn1
Building permit number:
Name of Permit Applicant
Dare Signature of Permit Applicant