30C-052 (11) 105 CLEMENT ST BP-2017-0421
CS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:30C-052 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ADDITION&RENOVATION BUILDING PERMIT
Permit# BP-2017-0421
Project# JS-2017-000695
Est.Cost:$32150.00
Fee: $209.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(so.ft.): 14505.48 Owner: SCHAEDIG CYNTHIA
Zonine: SR(100)/ Applicant: REYOR WILFRED G & HILDEGARD R CIO WILLIAM
REYOR
AT: 105 CLEMENT ST
Applicant Address: Phone: Insurance:
292 BENNETT RD
GUILFORDVT05301 ISSUED ON:9/28/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:build bedroom addition on top of existing foundation
(PREVIOUSLY PERMITTED)- make existing bedroom into office and add new bedroom
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 JO Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: O1: 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 9/28/2016 0:00:00 $209.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0421
APPLICANT/CONTACT PERSON REYOR WILFRED G&HILDEGARD R C/O WILLIAM REYOR
ADDRESS/PHONE 292 BENNETT RD GUILFORD
PROPERTY LOCATION 105 CLEMENT ST
MAP 30C PARCEL 052 001 ZONE SR(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid #07P9
//
Building Permit Filled out
Fee Paid
Typeof Construction: build bedroom addition on too of existing foundation(PREVIOUSLY PERMITTED)-make
existing bedroom into office and add new bedroom
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INI,E,WMATION 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
olition Delay /
Signature :u-� ml 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
- mit:
—city of Northampton Status of Per
R`= ^ - : Building Departmentr_
Curb Cut/Driveway Permit
cCn 212 Main Street Sewer/Septic Availability
OLr 28 Room 100 Water/Well Availability
N.rthampton, MA 01060 Two Sets of Structural Plans
DEPT or n.�Lr> a :::ptlUtIe41 587-1240 Fax 413-587-1272 Plot/Site Plans
uonTHn:.:Fr::�,nc, n Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 prooertv Address: This section to be completed by office
105 C/e ✓tu wi- Sof Map Lot Unit
rkVt fn LE 704 O i o* Z Zone Overlay DINdct
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2,1 Owner of Record:
hhLk. SC AA.e L5 /o5 at"n--e .--f 51, a(rex O/ole Z
Name 'm) Current Mailing Address/3/ b
l�0 p — VS- r
d/ r/'-e— �c6CC-_ti, _ Telephone 5'
Signa— t m
2.2 Authodzed Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ..2 o-, 55- 00 (a)Building Permit Fee
2. Electrical /4!o O o 0 (b)Estimated Total Cost of
Construction from (6)
3. Plumbing _ O _ Building Permit Fee
4. Mechanical(HVAC) n oO 00
5. Fire Protection d /� (y
6. Total=(1 +2+3+4+5) 321 /.5 'Y
0 Check Number `' y v
at
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissiomx/Inspector of Buildings
Date
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
' 14? Existing Proposed Required by Zoning
This column to be filled in by
PC— 05 2 - oo l Building Department
Loi Size • 333 acres 331st ccs
Frontage
Setbacks From
Side i.: R: L R:
Rear
Building Height (5 /
Bldg.Square Footage 1001/
Open Space Footage Z�
(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 0 DONT KNOW YES O
IF 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 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 c!
IF YES, describe size, type and location:
E. Wil the construction acclivity disturb(d aring, grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aoollcable)
CovuplChOv% thin AJcL mbKjartu1Ad..rear
New House ❑ Addition Replacement WindowsLeer-Anyration(s) ❑ Rooting
Or Doors O
Accessory Bldg. ❑ Demolition 0 New Signs [D] Decks [0 Siding[D] Other[OJ
Brief Duoiption o1f Proposed /I II pat/ty'O.�/(j-7 A J/� I
Work: 'IA be„,,Wih.n & Idr1ON n or "'Xrc6ng frun�� c la4h OA0 - I Yl�s
TOM
AttaAlterched Narrativeabon of g bedroom Yes No Re ovatiAddingunfinished
�In bew edroNo
basement om Yes Yes No rid
A =1 3
Plans Attached Roll -Sheet (s r1451).,,5.'rgL1 btr1 boot, cneri 3th✓ter/7 4 NN rV uJ L.d✓XM.
se. If New house and or addition to existing housing.complete the following:
a. Use of building:One Family )( Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
C. Is there a garage attached? Ai 0
d. Proposed Square footage of new construction. c2 a`t 51% T ft Dimensions IT rX /1,
e. Number of stones? het
.l 1 I
f. Method of heating? rte l W a ( Wr-"oc(o0o-v N Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction tCa ---L
i. Is construction within 100 ft.of wetlands? Yes K No. Is construction within 100 yr floodplain Yes No
j. Depth of basement or cellar floor below finished grade =�.5
k. Will building conform to the Building and Zoning regulations? )/ Yes No
I. Septic Tank City Sewer X Private well City water Supply
SECTION is-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Dare
1, ,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 Name
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 LlcenSod Construction Supervisor: CS - / 0 6 O Zy Not Applicable 0
Name orUuw nHolds!: C 1vt�ila Sr:�la cc/
toy C5 - in‘ o2k
J License Number
IS C'�rtmtv-t S{-. Ft YT- AA 6 loC2 ( 2-L2 - .2.. 017
Address Expiration Date
.01
<'/3 Ste-Vcv9
Signature Telep • -
9.Recls'teered Home Imorova,lment Contractor:(� Not Applicable ❑
rllvts .4. AAI
A YIA-A.ck
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L C.152,S 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 0 No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwelling of one(I) 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
ps.supervisor.CMR 780. Sixth Edition Section 10835.1.
Defmiti•n 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-war 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 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"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: (a ✓— C/erre n T 57L.
The debris will be transported by: b 4rsy...,,/, /S (-17- S,/e_
/
The debris will be received by: C- r7 fit /!/s',a or p4n'
Building permit number: /
Name of Permit Applicant � � ct e cel*
9-Z8 /6
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
_• ___+.]i Office of Investigations
1 Congress Street Suite 100
tk «= Boston, MA 02114-2017
� www,mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone#: _
Are you an employer? Check the appropriate box: Type of project (required):
I.❑ I am a employer with 4. 0 I am a general contractor and I
employees(full and/or part-time).
• have hired the sub-contractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. D Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9 0 Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. 9 We are a corporation and its 10.0 Electrical repairs or additions
3;gI am a homeowner doing all work officers have exercised their I I.D Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box Al 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 all 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
information.
Insurance Company Name:
Policy#or Self-ins. Lic. it: 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
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 certify under the pains and tet. ties of perjury that the information provided above is true and correct.
Sit .t_u_ — A .. - es ��- Date: � � �/6
Phone#: 7f3 Slye-- rs-519
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 d:
City of Northampton
"'' Massachusetts
tx
d ItCtt• a, DEPARTMENT OF BUILDING INSPECTIONS s. e
212 Main Street • Municipal Building
Northawpton, IA 01060 '`"rH A^0'
INSPECTOR
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 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/footings(before backfill.sonotube holes(before Dour).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
!2/ r�W
understand the above.
(Hom owner/resident's signature regg exemption)
I will call to schedulehall/regquired building inspections necessary for the building permit issued to me.
lt
Date ! —L6 - L 1� /
Address of work location /05 Ct'2 -e AL.I Si;
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7' City of Northampton
�.._...--- (_-D •__. I. . . ; Building Department
Plan Review
I- _ �. 212 Main Street
. .. I l A .i. r Ir I Northampton, MA 01060