43-029 (3) 400 WESTHAMPTON RD BP-2017-0382
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block:43-029 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BARN BUILDING PERMIT
Permit# BP-2017-0382
Project# JS-2017-000630
Est. Cost: $10000.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DANIEL PEDERSEN 106194
Lot Size(sq. ft.): Owner: CALCAGNINO STEPHEN C
Zoning: Applicant: DANIEL PEDERSEN
AT: 400 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
64 VILLAGE HILL RD (413) 531-9026
WILLIAMSBURGMA01096 ISSUED ON:9/21/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:STRUCTURAL REPAIR TO TOBACCO BARN,
NEW PIERS FOR POSTS, NEW SIDING
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 9/21/2016 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0382
APPLICANT/CONTACT PERSON DANIEL PEDERSEN
ADDRESS/PHONE 64 VILLAGE HILL RD WILLIAMSBURG (413)531-9026
PROPERTY LOCATION 400 WESTHAMPTON RD
MAP 43 PARCEL 029 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
oVNCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid C {y 3�r] �Kp
Building Permit Filled out
Fee Paid
Tvoeof Construction: STRUCTURAL REPAIR TO TOBACCO BARN,NEW PIERS FOR POSTS,NEW
SIDING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owned Statement or License 106194
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ON PRESENTED:
pproved 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
imolition Delay
% V17
Signature o Buil.ung Official 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.
Department use only
-- - City of Northampton Status of Permit:
: Building Department Curb Cut/Driveway Penne
212 Main Street Sewer/Septic Availability
SEP Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
- phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office Property Address:
Lfoo knif.S'bfteiv&Ptcr- ra- Map Lot Unit
F(t rel ct, MA . 0le)6rL
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
tTattet0 CAC 0AGA ilAO `16L, L57t-t+J-tr"t-o3 f?9
Name(Pint) Current Mailing Address:
4r- I _ p-caztrnuz 1 AAA - oto G a
dii. _ , Telephone
Signs re r 4"113-. S BG - S-9 917
2.2 Authorized Agent:
- Peele -M,. D134 r,M ._s__ _ e fey V-Ilyt lid( ad
NameiPrirint) Current Mailing Address:MS
`. AI V4.1c;OB o
, MA . Oi %
S J Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building m (a)Building Permit Fee
H 1o, 0 00
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee /g[s`
4. Mechanical(HVAC) ®5
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number 33 7
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings
Date
Section 4. ZONING All Information Must Be Completed, Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
t.OtSizc tf its
Frontage
Setbacks Front f/Oo Ft,
Side L:+/w R: f/" L: R:
Rear 4/ao (—a
Building Height
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a?�Special Permit/Variance/Finding ever been issued for/on the site?
NO ® DONT KNOW 0 YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO Q
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO fa
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House 0 Addition 0 Replacement Windows Aiteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ® Demolition 0 New Signs [0] Decks [O Siding(DI Other[O]
Brief Description of Pro -
Work: cert c3w.a.I r`era1r-M +obeuo, barn, ! ¢,w piers car pos�sf ne.,,a
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.if New house and or addition to exisdng housing,complete the following:
a. Use of building:One Family Two Family Other
b. Number of rooms in each family uniCNumber 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 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
It Will building conform to the Building and Zoning regulations? Yes No
I. Septic Tank _ _ City Sewer _ Private well City water Supply
SECTION Ta-OWNER AUTHORIZATION•TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
{C-6,b{an'3 Oct— h6O lA L. ,as Owner of the subject
Properly �
hereby authorize —T o.ci e( ?eA-eAt/_
to act on my behalf, in all matters relative to work authorized by this building permit application.
c9 Iq i 14
s.�,i!of s-�.. n ,�i - Date
{..bic )e I Pt4t rrer-- ,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 Nance
alfei/a
Sign gem Oat
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable Li
WOMB of[item JdR /��+Holder: rp.1 Y2a'<- _ Cs — 106 jp ict License Number
061971 2-01
Address Expiration Data
913 -53/-gozb ..
atu Telephone
9,Rapistete� dNome�h Penvement Contractor. �{- Not Appllcabie ❑
Ilr,l^te1"
r O'in* r Cu .I c . dly
Company Name Registration Number
fob ui *ire 14;ll Rot , t i;11;o_i , rnA - 11113/2°/g
Address Expiration Date
Telephone 913-53/-'f 026
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GI.p.152,§25C(8}}
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......2Q No 0
1.1. - 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,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.I.
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 th a one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that he/she shall be
responsible for an 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"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
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: 400 W elk itaay.p+ov. fd .
The debris will be transported by: A,nnhfr'ith—r T62.uctc q--
The debris will be received by: .TA-CLe-y (2Z -cYC Li JC,
Building permit number
Name of Permit Applicant —i�,, ;e( (461-4- s-cr_
tri
Date Signa re of Permit Applicant
The Commonwealth of Massachusetts
,_— Department of Industrial Accidents
= t Office of Investigations
G e=
,_— 1 Congress Street, Suite 100
=1= Boston, MA 02 114-2 01 7
www mass.govidia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information IA
'ty� Please Print Legibly
•
Name(Business/Organization/Individual): �eat..(,l P.( r cr v-ci(\ y ,rvl JA
Address: (}{ kid to ge !+ i l , I ti o.vhs b,Are wtA_ 0 0
City/State/Zip: Li; II;o.n.sh a Phone#: ` 13 -53 1-9 02.6
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2.El I am a sole proprietor or partner- listed on the attached sheet. 7. ,,7,3 Remodeling
ship and have no employees These sub-contractors have R. ❑ Demolition
working for me in any capacity. employees and have workers'
comp. insurance? 9. ❑ Building addition
[No workers' comp. insurance �./,
required.] 5. 0[ We are a corporation and its 10.0 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' right of exemption per MGI.
Y comp. 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
'My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners 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 slate 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 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 c. 152 can lead to the imposition of criminal penalties of a
frac 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 certi under he pains and penalties of perjury that the information provided above is true and correct
Signature: 1 Date: 9 —/9 Ib
Phone#: -1/3-53/——702_C
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
Contort Person: Phone#:
2� r � INeckj .,pbn,., r41
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City of Northampton
d ISMarvfI I ,,,\ �,i.>�n.E,q�0
Building Department !r"Av.r, r 73N^ r
Plan Review `` ` ��£
212 Main Street flit w ri;9 }.ac_
Northampton, MA01100660 / Q
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