24C-198 (5) 86 MASSASOIT ST BP-2017-0417
r)s#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24C- 198 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateen GARAGE BUILDING PERMIT
erm[t4 BP-2017-0417
Project JS-2017-000691
Est.Cost:$50000.00
Lee: $325.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREGORY QUILL 105857
Lot Size(su. ft): S wner: GHAZEY RO;. •T G&HOL..Y N
Zonino: Applicant: GREGORY QUILL
AT: 86 MASSASOIT ST
Applicant Address: Phone: Insurance:
23 E HADLEY RD (413) 695-4195 WC
HADLEYMA01035 ISSUED ON:9/28/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR/RENOVATE 5 BAY GARAGE
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 9/28/2016 0:00:00 $325.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File p BP-2017-0417
APPLICANT/CONTACT PERSON GREGORY QUILL
ADDRESS/PHONE 23 E HADLEY RD HADLEY (413)695.4195
PROPERTY LOCATION 86 MASSASOIT ST
MAP 24C PARCEL 198 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED It
Fee Paid
Building Permit Filled r t ,�
Fee Paid -
,Tygeo_fConstruction: ,REPAIR/RENOVATE 5 BAY GARAGE.......
New Construction
Non Structural interior renovations
Addition to Existing
Acc ssory Structure
Building Plans Included:
Owner/Statement or License 105857
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I/NFO TION PRESENTED:
4 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 ElmStreet Commission Permit DPW Storm Water Management
Demogn D ys% ,
Si. 77(
. e o uil dos 13icial 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
i _ E11/ED iCity of Northampton Status of Permit
'Building Department Curb Cut/Driveway Permit
iiiit i 212 Main Street SeweriSeptic Avallab ity
t� LVI I Room 100 waterMea Av ity
...- N rthampton, MA 01060 Two Sets of Structural Plans
DBr cr C141IINC+Ilea:
O'+Ye
uomrauvrca.n,pFulrte 41 587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION t -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot Unit
g4 -g(0 hvas5 a_30 it 514
Zone Overlay District_
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
st.i Owner of Record:
(Cn6vrt- a- R. Li (,11r,c�z-eL _4itt W\ asSa Snit 5±
N e(P'et) C e ailing .
cfrix,„; Ii SZ 0
elephone
S tore
2.2 AuthoAgent:
GI aQut \ \ .+Y-
1. r 0. f r
Name(Print)
Current Mailing Address:
• C _fa . .' ti CO Co 4 S. 4 i 9 S
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. BuildingC ) O n (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4 +5) 51)1 CDD0 Check Number 30t C1 .$ 3015
This Section For Official Use Only
Building Permissued'Number Date
Signature: W
BuiWug Commissioner/inspector of BWdi gs 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 Dllsri in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R::���j
Rear 0 J t'
Building Height I
Bldg.Square Footage niv
Open Space Footage
(Lot area minus bldg&paved
parkas)
ti of Parking Spaces
Fill:
(volume&Location)
A. Has a Sp • t Permit/Variance/finding ever been issued for/on the site?
NO DONT KNOW 0 YES Q
IF YES,date issued:
IF YES: Was
^'the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES O
IF YES: enter Book Page nd/or Document it
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?
NeeJs to be obtained O Obtained ll , 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
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,exc tion,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Wi dows Alteration(s) u Roofing 12(
Or Doors
Accessory Bldg. D Demolition ❑ New Signs [O] Decks [0 Siding[O] Other[0]
Brief Description of Proposed r t- /
Work: (Pp Proposed
I f vo'Tl1+� -i bcty 5grct (3Q it -14
J J windows
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ga.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?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
9. 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
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
ORCONTRACTORI � APPLIES FOR BUILDING PERMIT
I, "n " ll G , `az-4) q ,as Owner of the subject
properly J /� I U ' 1
herebyauthorize Cin (The \ Jt) t tl `\Cl'1 47 IM LA IA Cl LLC
to act • By •- If,in all �•.i. 4-lative o work authorized by this building permit application.
G
40 ' �� R ! I a c -( (P
Signa - /Owner I Date
I, G re I/t l k ,as Owner/Authorized
Agent hereby declare t 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 Bed ry.
0
Print Name ' `�—s,� i
Signature/Agent �J — * Date ��
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder: ( � CPQ Q u l /0 C. ?
`�iL (J1 h (} 1 License Number (�
LiAddress 1 \lz(�'4,�,( `C-!.� `-kOtAI{2�I C ` 0 �� Expiration DateO`
�, L& t c ?c 4 ( Q $
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
If flL( f
Company Name Registration Numbers QQ
t (d � O
Address Expiration Date
Telephone
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 affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes ❑ No ❑
11. - 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 108.3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,oris 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 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
The Commonwealth of Massachusetts
w— Department of Industrial Accidents
L
e?YT= Office of Investigations
—
t•_ 1410=s 1 Congress Street, Suite 100
="r11=ry Boston,M4 02114-2017
www.mass.gov/die
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 1 Please Print Leuibly
Name (Business/Organization/Individual): 1hQS Q yv, U }1f J- LLI C-
Address: o` CT 3 E o1/4.4 I_Q til C � \ �'-1 Iy 4 Q co 2,
City/State/Zip: Phone#: J 41 R Q s--
Are
Are y an employer?Check the appropriate box: Type of 1roject (required):
1. 1 am a employer with ' 4. ❑ I am a general contractor and I
employees(full and/or part-time).' have hired the sub-contractors 6. L New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Q `emodeling
ship and have no employees These sub-contractors have S. 9 Demolition
workingfor me in anycapacity. employees and have workers'
P tY 9. ❑ Building addition
[No workers' comp. insurance comp.insurance.:
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.9 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MOL 12 ❑ Roof repairs
insurance required.] t c. 152, §I(4),and we have no
employees. [No workers' 13.9 Other
comp. insurance required.]
*My applicant that checks box#1 must also 110 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 subcontractors 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: A
vv. C �.,i Q 1/-C)`-
Policy#or Self-ins. Lic.#: \J. C Z k"� ,�,'St j L Expiration Date: �0, 713,02
1 .(n,, 1
I,11
Job Site Address: V V PCI V Q ✓ R rciclk :I. Loop City/State/Zip: IQQ d INA Q ( 753
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 penalties QII fperjury that the information providedFabove is true and correct.
CA.kA.
Signature: .9- t � )4Date: `p •—a..�(j'�n
Phone#: ( L Ca'1 S 7 R 5-
-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 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: G VA_C15 S C2 5 n ) t S
The debris will be transported by: \,(0,G� ✓2 3 y��� t (
The debris will be received by: 1`t t -p Q Cj CU I ✓k 5
Building permit number: J
Name of Permit Applicant R yvl v 4 1 LC
Date Signature of Permit Applicant