17C-084 (7) 87 CHESTNUT ST BP-2016-1561
GIS COMMONWEALTH OF MASSACHUSETTS
Map:Baock: IAC-084 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: REPAIR BUILDING PERMIT
Permit# BP-2016-1561
Project# JS-2016-002666
Est.Cost: $14500.00
Fee: $94.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: KEVIN MAY 4010
Lot Size(sq.ft.): 10890.00 Owner: ELLISON PAULA K
Zoning: URBp00)/ Applicant: KEVIN MAY
AT: 87 CHESTNUT ST
Applicant Address: Phone: Insurance:
149 DEPOT RD - PO BOX 165 (413) 522-0501
NORTH HATFIELDMA01066 ISSUED ON:6/29/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE ROOF, REPAIR DECK - FLOOR
BOARDS THAT ARE ROTTED AND REPLACE HANDRAILS - REPAIR CEILINGS
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: FeeTvpe:
Date Paid: Amount:
Building 6/29/2016 0:00:00 $94.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck-Building Commissioner
File#BP-2016-1561
APPLICANT/CONTACT PERSON KEVIN MAY
ADDRESS/PHONE 149 DEPOT RD-PO BOX 165 NORTH HATFIELD (413) 522-0501
PROPERTY LOCATION 87 CHESTNUT S7'
MAP 17C PARCEL 084 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPI (CATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid Ar 4CCT- 7j
Building Permit Filled out
Fee Paid
TypeofConstruction: RFPLA F ROOF,REPAIR DECK-FLOOR BOARDS THAT ARE ROTTED AND
REPLACE. HANDRAILS-REPAIR CEILINGS _
New Construction
Non Structpral interior renovations
Addition to Existing
Accessory Structure
Building Plans Included,
Owner/Statement or License 4010
3 sets of Plans I Plot Plan
THE FOLLOWING ACFION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IFORMATION PRESENTED:
..."-Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Projecct: 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
emolitio la
Sig are of Building Ofticiar 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 infonnation.
Department use only
co City of Northampton Status of Permit:
`? -' Building Department Curb Cut/Driveway Permit,,,- _
Oe zi 212 Main Street Sewer/Septic
r« `� Room 100 Water/Well Availability
Li c
Northampton, MA 01060 Two Sets of Structural Plans
;7 43 phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans_
< _Otter Specify
• - eT•N TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address' 1 ,[ This section to be completed by office
9 1 C.JJEJ'�1 "t-t1�_ S�,`tI ' / Map Lot... ..,_Unit
rt- of &N C.0 /"\A d I Ot Zone Overlay District
ElmI St.District CR District
SECTION 2-PROPERTY OWNER$HIPIAUTHORIZED AGENT
2.1 Owner of Record: 2 �- C t ie S f N Ur 5 t -
PAvLa E[ L7 Sin/ ri--01e6JC6, nAA 0 ( 0 G
Current Mailing Address:
• 6, 'o .
Nra - sus - o �t � 3
a Telephone
g . ure J l�
2.2 Authorized Agent: Pt I> Pc+- F(a I,
r� eVx1 MAN( i utw c� LLL; t`(,ogcf 1441f'(Eo _rit orobi
Name(Print) Current Mailing Address:
`arwt �y _.L- f!3- 522-3 -•o raj
dile: e Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed bypermit applicant
1. Building f % 0 (a)Building Permit Fee
2. Electrical f a7 (b) Estimated Total Cost of
Construction from(6} _
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5 Fire Protection
G. � SOC1
j' e
Total=(1 +7+3+4+5) �^/� (DOCheckNumber
This Section For Official Use Only
Building Permit Number: Date
Issued:t
Signature:
Building Gommissionerllnspector 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 column to be Mk,in by
Building Department
Lot Size .... ,. .. . .
Frontage _._ .. . _..
Setbacks Front
Side L. R. . . L R .. ...
Rear
Building Height
Bldg. Square Footage o -
Open Space Footage
(Lot area minas bldg&paved
pal king) ...—..—
k of Parkins Spaces -'
Fill:
(volume a Iocnrion)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES O
IF YES: enter Book Page and/or Document it
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q ns 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained Q , Date Issued:
C. Do any signs exist on the property? YES O NO O
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 Q
IF YES, describe size, type and Location:
E. Will the construction activity disturb(clearing,grading.excavation,or filling)over i acre or is it pad of a common plan
that will disturb over acre? YES Q 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 ❑ Replacement Windows Alteration(s) I Roofing n
Or Doors ❑ _._. _.. __.__...
Accessory Bldg. ❑ Demolition ❑ New Signs [DI Decks [17"' Siding ID) Other[DI
Brief Desc ion of Propose Fl oo -' & CI
Work. ,Thge�gnet ace greatit Rt{ ti etedL,A.. �ltff s
Alteration of existing bedroom Yes No Adding new bedroom Yes No • /i l n v7?f f_5Attached Narrative Renovating unfinished basement Yes No 44
Plans Attached Roll -Sheet
Sa.If New house and or addition to existing housing.complete the following,
a. Use of building:One Family Two Family V" Other
[
vet 4,„„, CP 12.+
b. Number of rooms in each family VY uniF7ND w.. / 3 Number of Bathrooms�ZNO etaktalAD
c. is Mere a garage attached? At/t0
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodsfoves Number of each
g. Energy Conservation Compliance.C' _Masscheck Energy Compliance form attached?
h. Type of construction Rtdo{nc4 DCCIe,•CelL ant 5
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 arid 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
, as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this Outdate permit application.
Signature of Owner Date
111.1111.11111.11.111.111.111.11111.1111111C---
,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 Nana
Signature of Owno&iAgent Date
SECTION 8-CONSTRUCTION SERVICES
�
g.1 Licensed Construction Supervisor: � Not Applicable E
Name of License HaIdar: `(E V, .t.L 4M . MA"
.'� 'cense Number,
!t9 Tot RoRD ?O.604- 1(ess pa "+2V Cs n 44p/y ✓
Address Expiration Dale w+}
Signature ...... Tet"ghees p—� y- �'`Q2 ><L^R7... 1 Wg/p 0 jI t
rf1LLL //JL'�b/er0[ �a'L.lV / f/� i I
9.Ret'stercd Home Improvemen Contractor: Not Applicable f
' .r
Co .an Na a Registration Number
Address Expiration Cate
Telephone
I _
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 £ No E
Lt. - 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,prpvided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 1,08.3.5.1.
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-near period shall nut be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,tryst 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" --- ea and assumes resp. sibility for compliance with the State Building Code,City of
Northampton Ordinances,Sm and LAT!Zoning • id State of Massachusetts General Laws Annotated.
Homeowner Signature - et.
The Commonwealth of Massachusetts
4 Department of Industrial Accidents
rg''.— Office of,investigations
t'
♦ L:
` 600 Washington Street
G Boston, MA 02111
- www.mass.govtdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Businesslforganizationandividuat):
Address:
City/State/Zip: Phone#:
•
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a em loyer with 4. 9 I am a general contractor and I
yeas (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
shipemployees These sub-contractors have 8.and have no employees and have workers' LI Demolition
wworkingforme in any capacity. 9
9, Building addition
[No workers' comp. insurance comp. insuronce3
required.] 5. 0 We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp, right of exemption per MGL 12 ❑ Roof repairs
insurance required.] ' c. 152, §1(4), and we have no
employees. [No workers' 13.9 Other
comp.insurance required.]
"Any applicant that checks box ql must also fill out the section below showing their workers'compensation policy Inlmmation.
THo meownens who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicaung such.
:Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. if the sub-contractors have employees,they must provide their workers'comp.pottcy number.
lain 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.Lie. #: 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 MOL e. 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 coveraee verification.
I do hereby certir under the pains:nd penalties of perjury that the information provided above is true and correct.
Signature.010. AL it Date: 4fr
Phone#:
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
p Massachusetts �a
4C.?.
DSPRRTt 1'T OF BUILDING INSPBCTTONS
yy 212 Main street •
Municipal Building
F�
f
Northampton, MR 01060 %/ `
TNSHBCTOR
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 andtor farm structures. A person who constructs more than one home in a two-
1 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: CU C,esi ,v/ �hae± Vfl0n�C6- ,
14
The debris will be transported by: bUrap54e2
The debris will be received by: Dos no
Building permit number:
Name of Permit Applicant Ke t D_ Mk f
1
„KA
Date Signature of Permit Applicant