24A-089 10 DICKINSON ST BP-2017-0112
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24A-089 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-2017-0112
Project# JS-2017-000183
Est. Cost:$28000.00
Fee: $182.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GERALD ARCHAMBAULT 010788
Lot Size(sq.ft.): 5227.20 Owner: BARAJAS-ROMAN MAGALY&MARIA ELIZABETH BARAJAS-ROMAN
Zonina:URA(100)/ Applicant: GERALD ARCHAMBAULT
AT: 10 DICKINSON ST
Applicant Address: Phone: Insurance:
68 AMHERST ST (413) 552-7410 O Workers Compensation
GRANBYMA01033 ISSUED ON::8/1/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL 2 BATHROOMS,REPLACE CELLAR
STAIRS & INSTALL 2 REPLACEMENT WINDOWS & DOOR
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 8/1/2016 0:00:00 $182.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File a BP-2017-0112
APPLICANT/CONTACT PERSON GERALD ARCHAMBAULT
ADDRESS/PHONE 68 AMHERST ST GRANBY01033 (413)552-7410 O
PROPERTY LOCATION 10 DICKINSON ST
MAP 24A PARCEL 089 001 ZONE URA(1001/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid Ofie1—
Building Permit Filled out
Fee Paid
Typeof Construction: REMODEL 2 BATHROOMS,REPLACE CELLAR STAIRS&INSTALL 2
REPLACEMENT WINDOWS& DOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 010788
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOILMTION 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
D lition Delay r
VVii. eyV-7701-7
Signa ure of Bui 5ma 0%'tial 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.
• �' a Depanment use only
Cry CT Nor` a ' )ton Status or Penni, `
JI.& 2 7 2318 Bull no Decaartmeas C It Cu✓Dnver y Fe mit
212 Mari Stattel SearebSeprio g rill etx
von OF BUILDING INSPEC11, ROOIM 100 V1 jVhter-Ahlei Availability
NORTIAMPrON rwaiova Not attratptcra MA 01060 Two Sets cfo a ur Plans-
I phone 413-587-1240 Fax 413-587-t 2r PloV$d Pans
/ethos,Spam-a € _ _ _
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING I
ISECTION 1 -SITE INFORMATION
I IT Pronem Address: T r aca�on to bec npie o
3 by office
/0 'PI �eh16,¢On SMt M2p Loi,- Umt
A10,4044‘ ✓L. Pic., . Tone Qverlay Ods nct
Elm St.District _ CE District- _ -.I
SECTION 2-PROPERTY OWNERSHIP/AU T KORIZED AGENT
2.1 Owner of Record:
P...; O ' eqn S'I'
i Name(Prim) trent Bailing Address:
I _fig .t 70- 387 - if-2
rr-
.eFnene
2.2
Au
thor)izedAeennt:
Yf� .CeMc Nilr //2 Y1] PhSf `± r ,��-y._
eJ / me Mag)))):Aha a=s
I A . ry ' . 5 /3 3-112_,.....79_/0_____
et
Taieorione
SECTION 3-ESTIMATED CONSTRUCTION COSTS
rem 1 Estimated Cost{Dollars)to be OSicizt Use Only
I completed by perrnit aooiicant
1 1 Building I (a)Eiriding Permit Fee
Ooc0J
Electhcel ®� (b)Estimated Total Cost of
Construction tom(6)
?. Plumbing i Building Permit Fee
_ OOO _ � (�
4 Mechanical (HV4C) J
15.Fire Pmtecton I I
6. Total=(1 .24.3+4+3) ... 1 a ton . I Check Number / '.
C This Section For Official Use Only
3url'fng Permit Bribe' Date
Fseea
Signature:
IEY'lc " 'rnrssisne/lsp cr of Budms
[���//) ►-Cham �a, 4_444.. _
Email . f r e / 4,lima. e Yom. l (/,
Section 4. 2ON.NC 1 nil infor maton Must Be Completed. Permit Can Be Denied Due To Incomplete ln= mason 1
Existing Propose i Required by Zoning
This column to be filled in'by I
I1 12niS'g Dep.-vent _. — -
ILot Size
1 Frontage I /
Setbacks Front j
.,< ,
I Sine
Rea .____._ _ ..
Building weight ---- I =_- I =-__.._
Bldg. Square Footage Vo I j
Open Space Footage _ _ I — /
, I I _
pi .area s bid€8ed _,_,
parking)
,of Parking Spaces ._ —,
File
I (volume&Loa_oc -- _ .— ----- -- ..._.-- _
A. Has a Speciai Permit/Variants/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issue:.
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES enter Books Page and/or Documen`.F j
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained V , Date Issued: ___
C. Do any signs exist on the property? YES 0 NO cg
IF YES, describe s be, type and Location:
D. Are there any proposed changes to or additions of signs intended for the property? YES J NO
IF YES, describe size, type and location:
E. Will the construction activity disturb;clearing, °fading, excavation,or film s)over f acre or it part of a common plan
that wB disturb over 1 acre? YES 10 NC g
IF YES,then a Northampton Storm Water Maragement Fenn'from the DPW is required.
I,,
5E571015 5-DESCRIPTION:OF PROPOSED WORK/drank all a-pelicable)
Mew House Addition fl Reale:ament Windows Alteraelonfs) lLJ Poplins. n
Or Doors 0
Accessory Bldg. ❑ De_rnolfion LJ New Signs [Di Decks 1Cj Siding [L7] Other[0]
p
Enef Description of Propose: eel.? • e_
Work •. - i. .-445 - • c - re.Y TP, v r • a. • . +WO (U/
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
the
6a If New house and DC cd(util O.l to EXISC106 @O'15.❑Q. COC^DIEfEfEOZI01h'In[9Go:
a. Use of building: One Family Two Family Other
5. Number of rooms in each family unit Number of Bathrooms
c. Is there a garaoc attached?
d. Proposed Square footage of new construction Dimensions
e. Number of stories?
f Metnod of heating? Fireplaces or Woodstoves Number of each
g. Energy Coose,vation Compliance_ Masscheck Energy Compliance form attached?
h. Type of construction
r 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, fg& u. jtt `5 ILOfl%t4 as Owner of the subject
property �1 ' op �/ � '
hereby authorize Ge Y'Q-k.� AiYhan . it
to act on my behalf,in a matters relative to work authorized by this b`uilildiinng�p-e�rmit application.
SNS /.1at—��.
Signatur towner Cate
I eetrzi /.{�l'�� e.ri�� , as OwneriAuthorized
Agent hereby declare that the statements and i ormetron on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the alns and penalties of perjGeury
Print Name y"/ "fCyf Lo•µbl !/I'1,—
6
Sig .ure o(Ovmar/Agent Date
SECTION 8-CONSrR'SCi ICN SERVICES
E.1 Licenser Construction Supervisor: Not Applicable E
am?.oj LcsnsoHaloes ( 1 /� CS-0(0 -188
License Numbs-
Grin int PIA Ot033 Il
Address ExpErauon Date
'' &. ice, - ,�J�-- 751/0
Signature Telephone
9. Repister=_d Home Improvement Contractor Net APPlicabe
6c 19 a-nLeo - l a `? 9 / 3
Conine v Name Registration Number
63i ' Aigorsd- ent.e67 4'o33 III- 2-a—/7
Address Expiration Date
Telephone Yi ^
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 aff'davk mil result
in the denial cfthe issuance of the building permit.
Signed Affidavit Attached Yes £ No E
11. - Home Owner tsenintiofl
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,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 o 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 unoa
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Worker?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
, The CG✓.m✓Nno th cc Mr.ss c rrofs
'- , Cert rrnet 2 InW✓oI A_cc' e.wds
Office ` rr rsgcaors
i 'c�t—rte-'
c,, y V .
b ..,, ry or xt ce
•r Bosom, r✓"A 6211F
. - wrfcrwr.rr s goaFyia
Workers' ETompews.a. or ilranuronee Antirofinnfin Zti:Idetrr/ nr_zctorl E e e rniedna.,/rlinaloess
=_c Pee2n€ Information Flease heat Lee gp
r
/'
Name (Business/OrgenizatI ou/Ltrdividu2l): ( ea '.-
Address: 68 �( {O,p,4,f- ✓T-
City/State/Zip: 6 ...,. _. Alit_ 6. d Phone#: L//3 —„2-5.2—%79;a57
Are you an employer? Check to c appropriate box:
. I am a general contractor and 1 Type of project(required):
1.� 4
Iamaemployer with 6. U New construction
employees (full and/or part-time).* have hied the sub-contractors
listed on the attached sheet. 7. Q Remodeling
2.El I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
wodring forme in any capacity. employees and have workers'
[No workers' comp. insurance coma. insurance;
9. ❑ Building addition
required.] 5. ❑ We are a corporation and its I0.❑ Electrical repairs or additions
3.J 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 MOL
y p c. 152, §1(4), and we have no L..❑ Roof repairs
insurance required.]'
employees. [No workers' 13.7 Other
comp. insurance required.]
*Any applicant that checks box kl must also fin out the section below shondne their workers'compensation policy information.
'Ho meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-con tractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comppolicy 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: M
Policy id or Self-ins. Lic. #: V LA J Cs - 100-C.00V609-Xtg Expiration Date: r-/0 -/7//{l,,
Job Site Address: 1 0 Di c 1 M Son Sr City/State'Zip: Mo frit,: /%a O/060
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 ce ti_,under the pains and penalties of perjury that the information provided above is true and correct.
Signature: , , /40 Date: 7-09-6—/6
Phone Z//3 3-5— - `7//0
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. Cityilown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other ,
Contact Person: Phone#:
eiteflagith Viof 1,,, *wren.
,r/'
y P �. _ S t , a
Moth
'!c n F?. 91600 F S,'P�
INS?EC9OR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER MetaT1ONACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 730CMR 108.3.4 to act as his/her
construcaon 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 dwreflttag, 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 tailed to inspect work at various stages, which include
foundationtfcotings(before backfilf7, sonotube holes (before pour). a rough building Inspection
before work is concealed) insulation ins•ection if reauired and a final building ins ection.
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 pe,conn 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 net 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
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 :MMa- Street, No:t am=aton, :✓A 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: /0 Ok4r4 gnh ,
The debris will be transpo,te.d by: both t1
The debris will be received by: Valley p_ec/CZh
Building permit number:
Name of Permit Applicant 6ehticO, ,,, ctif—
41 I
Date Q'j�‘ Signature of Permit Applicant
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PROPOSED FIRST FLOOR PLAN
1/4" = 1'-0" II
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Batta
1111 nxefq,E AB Pc WINE-rs CV tsteenern6A MO
titn .. .E..aI STUD...
ttz BEDROOM Ni { w" Ha c ,
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a= �� BATH 2 � _ €
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_.... II CLOSET ; CLOSET 1 � a 1' �,:
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BEDROOM#2
1 I BEDROOM#3 1�
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PROPOSED SECOND FLOOR PLAN
1/4" = "1-1-0"
LoQcct ; . 5f Noy �i r�omet_
& 1/4-0._\,,k �rc0—,10 au 1t
fte e 11St- Ftoo\,-d-Bc<t4i roaw
New u,i,tqu_, !Vaud&tor/
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a
i DEPT
he \ lir 1 fkii--6o",
w`N8'e.u 2iw
afre /c
waif iir
o ST ✓ fror uce
i City of Northampton
Building Department
•
plan Review
n 212 Main Street
8 Nortthhampton, MA 01060
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