36-157 (5) 1136 BURTS PIT RD BP-2017-0294
GIS#: - COMMONWEALTH OF MASSACHUSETTS
Man:Block: 36- 157 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERE..D CONTRACTORS
Permit Building DO NOT HAVE ACCESS TOTHEGUARANTY FUND (MOL c.142A)
Category: BASEMENT RENOVATION BUILDING V ILDING PERMIT
Permit# BP-2017-0294
Project# JS-2017-000494
Est.Cost:$8550.00
Fee:$65.00 PERMISSION 15 HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MAURICE KIROUAC 097695
Lot Size(sa. h.): 13024,A4 Owner: NYKORCHUK JAMES&SUSAN
Toning: Applicant: MAURICE KIROUAC
AT: 1136 BURTS PIT RD
Applicant Address: Phone: Insurance:
45 WOLCOTT ST APT 1 L (603) 674-0877
HOLYOKEMAO1040 ISSUED ON:9/6/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:FRAME, INSULATE(WITH VAPOR BARRIER)
SHEETROCK BASEMENT(PARTIAL)
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 Deuartment 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 9/6/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
•
RECE: .D_ Depermeituse ony'
Cit/of Northampton
SEP _ 2 2015 E wilding Department curb CLj/Dnveway derma
212 Man Street SeweanSepnc Avallabr of
Room 100 Wa M/elf At ilabilrty- _
Orsr pseuc .a ,i� as
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xomHnMe .:gym oro o( haf'lpron MA 01060 Tw S�,�ar Structral Plans
phone 413-4-587-1240 Fox 4I3 587-1272 PIoOSIte Plans -1
Other Specl y
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR CC-MOL!SH A ONE OP.TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Properth/Atldress.
1(3 - Tvs section to be completed by once
� i3vrt-s f+ 22(
M p Lot Unt
L lortv'U A O \06� Zope Overlay Gis uric+
l •", I Em Sr Mather CB�strct -
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:-' � ( ` ,S 1 ION
Jaws JV a� {� �� 1136 ��./1s p, f ee( -IN tem Kt oto6a
Name(Prins rur2nl Malting.Address:
X111 3�
Telephone 0 I -> -7 c-{
I, it
•
Signature — e I'V
2.2 Authorized Aoent: '1 o �sOi yelp 77er
I
! Ar2Qll'.: *(t��G R f{0,- okc OA 6toYo
Na e(Print) Current bt lddress:
P
isei•• ....S..,r �_- 1, 4.o.3 67- 0977
Sig ature Tele one
/
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item
1estimated Cost(Dollars)to be Official Use Only
,completed by permit applicant
. Building rSSo 0O Ca)Building Permit Fee
2. Electrical !/ I (b) ECstngtPimated Total Costof
tit e (E)
3 Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3 +4-5) 5-3716, Bco ,Check Number /-4 Ur yI
This Section For Official Use Only
Budding Permit NumberfIr: Date
issued:
�`—� /�
Signature: i I
��
Building Commissioner/Inspector or Buildings Date
IIr
l i p s I ?.
Section 4. ZONING I al,Information Muss Be Cometeted. Bernet Can Be Denied Due To Incamp tete Berme-Ice
Existing Proposed Required by Zoning
This cscanto be tilled in by I
Budd re Department
Lot Size >.
Frontage __— _ - - - -.__-
Setbacks Font
Side L.=. R L _) R _. ____
:ear
Building Height F
Bldg Square Footage - - -- / - -
Open Space Footage % ,_ _
(Lotm n s blue&paved I _____
p ado e�
k ofdarking Spaces - - —
I
Fill
( ime&Location) ._ - s
A. Has a Special Permit/Variance/Finctns ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
:F YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page !. and/or DocumentA _ ,
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 69 i
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 01 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb bearing, grading, excavator, or Elting)over 7 acre or is it part of a o ommon plan
that will disturb over I acre, YES 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPWis required.
SECTION 5-DESCRIPTION OF PROPOSED WORN!chock all applicable)
New House U Addition Windows Altera'tion(s) I-1
.0
�,I
Or Doors CJ
Accessary Bldg. ED. Demoliilw New Signs (01 Cocks IraSiding t01 Other(CJ
Brief Work mono JAJst� Cwl /I work.. 11;;A:L r e /1�-�-^.f
?Art-0 si {._i
Alteration of existing bedroom Yes c51---No Addingnew bedroom Yesp STNo
Attached Narrative Renovating unfinished basement F"� Yes No
Hans Attached Raft _..._
Ga:ilf Ne00
whouse and or addition to eexist'a'nre hdushaa,-cornoPete the fonowih
a. Use of building One Pamrly Two Ramify Other
b. Number of rooms in each family unit. Number of Bathrooms
c. Is there a garage attached,
d. Proposed Square rootage of new cons/reckon Dimensions
e. Number cf stones?
f_ Method of heating', Fireplaces or Woodstoves Number of each _
g. Enemy ConservationCompliance. Nlasscheok Energy Compliance form 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 SewerPrivate well Cry water Supply
SECTION 7a .OWNER AUTHORIZATION .TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
,Sat\ N,ab d,,0
i, QV ,as Owner of the subract
property
hereb authorise /t — • G I rODLAAOJ �'�L
to act my beh f, in al /Hers relative to work a thonzed by this building permit application.
I i 1 'L - l6
Signature of Owner y Defe
.;:itS£x r ,f.'5.r_`sMr,`MMOSIS'ZfrAatg }F.....
1, j G,t•llti2/C-er..., gt rtq4C-- , ; c31Authonzed
Agent hereby declare Mat the statements and information on the foregoing application ate true and accurate,to the best of my knowledge
and belief
Signed underpthe pains and penalties oj perjury. �+ T
__ t&V" L C-£-.._. 7 \ t jt ay,s e t .
Ydnt Name -
Siynat��Agent (/ Date
SECTION 8-CONSTRU£TIO(y'SERVICES
8.1 Licensee:Constriction.supervisor: „,..---- Not
- Applicable
EE
NamLicense Holde•. , � eS vi-c0 (An- _to "
/.—
3 0 a * License umber
nddr =s Fepi teen Data
:AI (2, `/
-tore D�'77
ore i
Sig - Tel }one
_.._
9. oanS Inprwdment n nJ'o
Not Applicable7930.2 v
er
Company Mame R iai for Nu/tPt
—14 �........—
Sg--
Address
Address Expi -lion D. e
Telephone,_,
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MG.L.c. 152,§25C(6))
Workers Compensator Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result
in the denial of the issuance of'he building permit.
.Signed Affidavit Attached Yes.Pak. E No E
i. - 3oanae wirier Lxe•ara4ao
The current exemption fur`9mineowners"was extendedto include Owner-occupiedDwellinys of one(I) or two(2)families
and to allow such homeowner to engage an rabid/Al for hve who does not possess a disease,Provided that the owner acts
as supervisor.OMR 780, Sixth Edition Section 103.3.5.1.
Definition of Hoarcownen Person(s)who owna parcel of land on which he+'.she resides or intends to reside,on which there
or is intended to be,a one or two family dwelling, attached or detached sbubtures accessory to such use and/or farm
strictures A person who constructs more than one home in a two-year period shall not be considered a homeowner,
Such"homeowner"snail submit to the Building Oticial,ana torn acceptable to the Btu/drum Of ciao.that hefshe shall be
responsible for all such work performed under the building permit.
As acting Construction Sunery{,rypr your presence on the jab site will be required from tame 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 103(Liability of Employers to
Employees for infuses not resulting in Death)of the Massachusetts General Laws Annotated, on may be 11211 e for percents;
you hundersigned
nd ro igned"homeowner"
for r"you under this permsachusecertifies respousih'ility for compliance with the shote Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Iaws Annotated.
Edomeowner Signature
`nom The Commonwealth ofMassachusetts
omm
ph
• Department alf]intlar rrzal accidents
tri
' ',--ii! OficeofImestigation.5
r
N s'� 1> 600Washington Ssreet!
Cy ._,1)I i & Mom Mil 02111
aFs::-try a vvaaanhaeas.gowalia
Workers' Compensation insurance Allislavit: 1Pnada?ratContraerranratElechnis wms/PIlanuvnba;es
Applicant information , /�y ^ Meese (Print Latakia
Name(EusinesstOrganiration/Individual): ..r�',(t+eict_c. (1,. `_- ; a C.--
v.
Address: �b _ s , ri
City/State/Zip:i0... G.C- 0.� al-lb Phone D3_ !.
—
Are you an employer? Check the .ppropriate box: Type of project(required):
I.__ I am a employer with 4. Lf I am a general contractor and I 6. ❑ New ennstmction
employees (full and/or part-time).'" have hired the sub-contractors
2 I am a sole proprietor or partner-
listed on the attached sheet, 7, L Remodeling
ship and have no employees These sub-contractors haveg, _ Demolition
Demolition
worldng for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.! 9. U Building addition
_ required.] 5. fl We are a corporation and its 10.1-]Electrical repairs or additions
3, r 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.] t c, 152, §I(4), and we have no
employees. [No workers' 13.— Other
-
comp. insurance required.]
*Any applicant that checks box#1 roust also fill oat the section below showing their workers'compensation policy information.
Ilia 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 cheek 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
infarmatlon.
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 25.A 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 fee
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 DZA for insurance coverage verification.
I do hereby certify under the .ai is and penalties of perjury that the information provided afjov is Er e and correct.
Sirwature: Il l/� .. . r Dare: �Sv
Phone i': ...3 _ - a' .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 Th
._ t''1L_,s4a..—lsit �t
City ofdti!D G]??.
,ac its \
eke, ac' u
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212 Hai c c 0 municipal Building ,1
{et Yortnarta ton, - 01060 1.f
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER E;EE;MPTION ACKNOWLED GEMENT
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/£ootines (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
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
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: /1% (3(Art "S r Rt. . c..ciszsc aa,
The debris will be transported by: frint(f7J Cr f<l SLo�Ji,G
The debris will be received by: l/�{J..1,c__y G
Building permit number:
Name of Permit Applicant MA-LA ZICE a .
V)/641 ,
Date Signature of Permit Applicant
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