38D-015 (2) 20 CHARLES ST BP-2016-0876
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Mao-Block: 38D-015 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: renovation BUILDING PERMIT
Permitil BP-2016-0876
Project# JS-2016-001490
Est. Cost:$70200.00
Fee: $521.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
useGrouo: KEVIN WERNER 085114
Lot Size(sq. ft.): 5488.56 Owner: BLACK SHEEP DEVELOPMENT LLC
Zoning: URB(100)/ Applicant: KEVIN WERNER
AT: 20 CHARLES ST
Applicant Address: Phone: Insurance:
197 PARMENTERRD (413) 834-0488
B E RNAR DSTO N MA01137 ISSUED ON:3/15/2016 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN/BATH, ADD BATH,ADD &
REMOVE WALLS, ADD STAIRCASE & REPAIR ACCESSORY STRUCTURES, REAR ENTRY
ADDITION - amended 8/15/16 replace front stairs/lanind over existing
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 I/ 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 3/15/2016 0:00:00 $521.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck-Building Commissioner
-g ani CiC
File N BP-2016-0876
APPLICANT/CONTACT PERSON KEVIN WERNER Y i/bAn /LLu'U,t-V
ADDRESS/PHONE 197 PARMENTER RD BERNARDSTON01137(413)834-0488
PROPERTY LOCATION 20 CHARLES ST
MAP 38D PARCEL 015 001 ZONE URDU 001/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT q i
Fee Paid e2h4 447
Building Permit Filled out
Fee Paid
Typeof Construction: REMODEL KITCHEN/BATH ADD BATH,ADD&REMOVE WALLS, ADD
STAIRCASE&REPAIR ACCESSORY STRUCTURES, REAR ENTRY ADDITION-amended replace front
stairs/lanind over existing
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 085114
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFARMATION PRESENTED:
I. 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
moliti�a
Signature of Building 0 ' ial Date
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning& Development for more information.
D vane 4se a '
Cr of Northampton �s eus otP -
Bud g D parnenl 'Gut Cul/Dm/sway, s-n -
r, :� 212 Man meei aewaiSe h Av iawli '(
fuI.:11." 1 C Room 100 W terM/el vall I}-
'�QkUINO Lha Mon, MA 51005 Tn Sesc at JCLr PI n -
I NiG prone 2.13-.87 t 240 Fax 41 3 5 8 7-12 71 P ot/Si' Plans
I p Nsec-°rat to Other3Pecly _-�
Ma
I F '% - STRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH ACHE OR.TWO FAMILY DWELLING
LNG
um—
SECTION 1 -SITE INFORMATION
1.1 Prooery Address: v_ n ecnoc 6e complated by office -
&fo /'Char/es �- M p Lat — Ur•
I Par�IrC � H ,01o/OGp
Zone Overlap District
- Em tG Iret CSCstrct
SECTION 2-PROPERTY OWNERSHIPP/AUTHORIZED AGENT
2.1 Owner of Record:
bo,(e kelt jangl t bay(elle �ckOL 4
N t) Current Mailing Address
via tr '370
Telephone
Signature
2.2 Authorized Acent:
Name(Print) Curren:Mailing Adcress'.
11
SignatureTelephone
II SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Lisa Only
ccmoleted by permit aoofsant
1- Building $ T Sd . (a, Buiiding Permit Fee
2 Electrical (S) Estimated Total Cost of
Construction from(5)
3. Plumbing Building Perm is Fee
4. Mechanical(HC) g�
VA
5. Fire Protection I ]
dQ
Iota/ ,CheckNumoer , a I
This Section For Official Use Only
Building Permit Number: Iss
ze I Issued
Signature:
Buildirg Commissioner/Inspector of Buildings Date
Email a j r Calf a7 _ A . . ,ti
4 '
e_tiop d. ZONING ) All in'arna:on MLS:BeCamprmed,Pemmt Car Be De^red Due To Mom-Vetei f our. i
ivsting .:copse'. Requi d k Zonrng .
T rnh by
1 1 k:mg Cmmiartment
I
La:Size ,, .. - .,
F onta_e -r... __--_ Iff
Sc hacks Fon,
I Side -
— d_ ++ ''
Rear hos i— --^ 0 N
I I I PILE
h+;n:Height _._
Bldg
quare Footage . " I _ -
Oven r
SpceFoae __ I » nI
r t m_ebl kva, d I F+ u
P f
I t6lr
it of Padang Spaces ; I :wn-_ I __._.
Flit
(valmum mos
A. Has a Special Pernit/VariancJFi ncini ever been issued for/on'� the site?
a
NO 0 DONT KNOW 0 ,_o
IF YES, date issurias
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0 I
IF YES: enter Bock i Faze! ardor Document
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW 0 YES 0 f
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Cate Issued:
C. Do any signs exist on the property? YES 0 NO �R
ILF YES, desorte side, type and location. . - .._
Are here any proposed changes to or additions of signs intended for the property? YES 0 NO 9
IF YES, describe type and location: �� .. _
E Will the construction octivIty disturb(clearing,a,g ad r y valor or Slid';)over 1 acreoris f r.zd of n or,pier
1
_ wi:l disturb over 1 acre? ES 0 NC a
IF S,then a Nota p:2n Smrmtate Nians . d'_P_rmit from time DPW s remuMea
I
e
SECTION!5-DESCRIPTION OF PROPOSED WORK!check all aociicable) 11
New House Addition n Recdaamert Windows Alaration(s) a Roofing r
Or Doors C
Accessory Bldg n Demolition New Signs ICJ Decks [LiSiding ]o] Other IC]
Brief Description of Proposed ( //
Work: O doted? 04)... ✓( aC /�crr//ir/, C1k 'yr ii-ti f Slap r7'S
Alteration of existing bedroom Yes 7- Nc Adding new bedroom Yes A No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa If Maw house and,or adthtion tc exisctna housur!a;corafete the fodlorarino
a. Use of building One Family X Two Family Other
b. Number of rooms in each family unit: ? Number of Bathrooms
c. Is there a garage attached? fO
d. Pmoosed Square rocfaoe of new construction F X V Dimensions
3Z 9
e. Number or stories? n�
Method cf heating? t�'a 3 Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. " p Masscheck Energy Compliance form attached?
h. Type of construction l2ec '�71- >14c 4,i
i. Is construction within 100 tt.of wetlands? Yes _ Neis construcdan within 100 yr. floodplain Yes 'V
J. Depth of basement or cellar floor below finished grade F
k Will building conform to the Building and Zoning regulations? Ves No.
F. 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, '-'alC ""Tr1'e as Owner of the subject
property
hereby authorize Kp U(N tart tug-
to act on my b - all matters reiativ to work authorized by this building permit application.
k , FAA
Signature of Owner Date
I, 0.4 !Vf _ g'0_5 as Owner/Authorized
Agent hereby declare that the statement nd information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Signed under thecains and penalties of perjury.
Print Name L �, L�// t 4Sig nature of Owner/Agent r Cate
SECTION CON$TRUCiIO%9ERt')C SSs Licensed __...
ease sen Sunerviser: Not Ttsticat'e E
,� or G (e
hare or iA Heider I` �.�viva O n CI usenu Number .—
Adorass Expiration Date
Slericture Telephone
�E. P.eolsternd I-lorrte':Improbamen£bon rex areT'77-777-5-77'_ _ Nct Applicable E
Company Name Registration Number
Address Expfteton Date
Telephone..........
SECTION 10.WORKERS'OOMFEENSATION INS[MANC6 - - „25C(6))
.,AFFIDAVIT(ft7 O.L c.16Z,Y
Workers Compensation Insurance affidavit must be completed and submitted with this application Failure to provide this affidavit will result
-.,the denial or the issuance et the building permit.
Signed Affidavit Attached Yes E No
;11onie OwnerEs-emotion
The current exemption for'homeowners"was extended to include Owner-oec unied Dwellings of one(I) or two(2)families
and to allow such.1,;meovmer to engage an±d:v=d:'al for hire who does not possess a licecse,provided that the owner acts
as supervisor.CMR 780. Sixth Edition Section IOS.35.1.
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 anal/or:amt
s6vcnres.A person who constructs more than nae home in a two ear period shall not be considered a homeowner-
Such'homeowner"shall submit to the Building OGicial,on a form acceptable to the Badding Official.that he/she shall be responsible for all such work performed under the building permit.
As noting Construction Supervisor your presence on the job site will be required from tune to time, during and upon
completion of the work for which this permit is issued.
Aliso 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 mar be liable for percent's)
you hire to perform work for you under this permit'.
The undersigned"homeowner"certifies and assumes responsibility for compliance with:he State Building Code,City of
Northampton Ordinances,Stare¢.cd Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature__„
e Commonwealth of F den
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www.reo2.53.gov/dia
Workers' Compensation runsuranne Rin idatit:. Inihders/Contrac?-orc'El ctr:ctanssPfae,uclners
A ssMicant Information
Please Print LeafbIv
NameBusiness/OrganzationQndividua): Dale ;,,sec i/— 2J( ntele N/cGCpg-
gLdbits /A✓ 13 S'0Address:
City/State/Zip: or Asa �
Phone #: ( 3. 2320
Are you an employer? Check the appropr'u¢e box:
Type of project (required):
I4. I am a general contractor and I
I.H e am a employer(fullwith ❑ 6. ❑New construction
t-� employees (full and/or part-time).* have hired the sub-core:actors
2gl I am a sole proprietor or partner- listed on the attached sheet, 7. ❑ Remodeling
ship and have no employees These sub-contractors have o _ Demolition
working for me in any capacity. employees and have workers' ❑
9. Building addition
[No workers' coin?. insurance comp. insurance.:
required] 5. ❑ We are a corporation and its 10.7 Elechica] repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.n Plumbing repairs or additions
myself [No workers' comp. rght of exemption per MOL 12.❑Roof repairs
insurance required.]t C. 152, §1(4), and we have no `� "
employees. [No workers' 13K Other dv.
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below shoving their workers'compensation policy information.
ilio meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContracors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those end^_es have
employees. If the sub-contractors have employees,they must preside their workers'comp.policy number.
Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy and joh 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 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 fonvarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Q 7 2 i Date: P/1176Phonef¢. yf3 33 l' 2 26
i
' 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 No : the—6:ton
a - Massachusetts
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INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER E) Tv27:IONACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under T8DG[vfR 1008.3.4 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 ore 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 reputations_ The inspection
process requires that the building department be called to inspect work at various stales,which include
foundation/footings (before backfill). sonotube holes (before pour). a rough building inspection
(before work is concealed). insulation Inspection (if reouired) 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
‘1'5 Gie r"C,. C Ll Q4.16 understand the above.
(Home owner/resident's signature_ requesting exemption)
will call to schedule all required building inspections necessary for the building permit issued to me.
Date
1 / /1 yff (
Address of work location Q C�l �..cr le S 51L
1u°��
City of Northampton 212 Main Street, Northampton, ivtA 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: Zo C a (eS
The debris will be transported by: 4il ,teU'S O 0- k 0,42vThe debris will be received by: 4 (h A 'S. rr. a FFk4 (�
Building permit number:
Name of Permit Applicant q,le kit - Jakoi
Wri lb _I,• 4111
Date Signature • Permit Applicant
20 Charles St-Site Plan
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City of Northampton & „,i.`s .,
//// f Building Depart
r� Poen Review
212 Main Street
I Northampton, MA 01060