06-043 (3) 271 HAYDENVILLE RD-Route 9 BP-2017-0403
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:06-043 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Bath reno BUILDING PERMIT
Permit# BP-2017-0403
Project# JS-2017-000669
Est. Cost:$5000.00
Fee: $6500 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MAURICE KIROUAC 097695
Lot Size(sp. ft.): 30622.68 Owner: CHAPIN-BISHOP CATHERINE A&PETER E BISHOP
Zoning: SR(100)/ Applicant: MAURICE KIROUAC
AT: 271 HAYDENVILLE RD - Route 9
Applicant Address: Phone: Insurance:
45 WOLCOTT ST APT IL (603) 674-0877
HOLYOKEMA01040 ISSUED ON:9/23/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:NEW TUB & TILE, NEW VINYL FLOORING
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:
FeeType: Date Paid: Amount:
Building 9/23/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
"L.-CBI/Fp
Depzrtmentusz only=
Cib, of Northampton stains oP Pprmt - -
_,. C B Department core cuvonve vay Permit -
212
212 M Maln iStreet Sewe/SepLc AvallabNty
Room 10O WaterM ell Avallabilit
Northampton, MA 01060 rwo seLsofStrucTuai Plays
----pntwde 413-587-1240 Fax 4'13-587-1272 Blot/Site-Plans - - -
Pthzt Specny — v
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 1
1.1 Pro erh.,Atld ess'. 1 This eccmn to be completed by office
„7/ 4y�Iullrf-V-C R ,INaP Lgt 'Unit
Lc Q S ' �.Qt. ton OverlayD .riot - -
Elm St Dstrct LB Dstricf
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Sc C . 0271ybk\(%u-F-- rZbp ,
Name(P � Current Mailing Address: t� Mh
Signs -
2.2 Authorized Agent: S 424A-00T1— S'r. 4prri IL
/- Wood. G g a-ce, --(2 // .o/ ro , . oIoyo
Name(Punt C Tent Mang Adress:
yarn. At. ._ I . (Gy 03 674/ - 0S77
ign ure Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be - Official Use Only
/c/ompleted by permit applicant
1. Building y1 ?5-0 q1 • 0 (a) Building Permit Fee
2. Electrical V 1 (b) Estimated Total Cost of
Construction from(6)
3. Plumbing /�DO DO Permit
Building Fee
4 Mechanical (HVAC)
5 Fire Protection
16. Tota/=(1 +2+3+4+5) goo 6 1,Check Number b/o / I
This Section For Official Use Only
Date
Building Permit Number Issued'
s _
S
Signature: �grair � .,
Building Commissioner/Inspector of BuildingsDate
EvU
rat Lore1 0I
Section 4. ZONING AIL Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be aged in by
Building Department
Lot Size ... —
Frontage -
Setbacks Front
Side L. A( L R.t_ __ _,....
Rear . —
Building Height
Bidg. Square Footage __ r—_ / < _
Open Space Footage %
Ret area minus bldg&paved ,)
parhna
F of Parking Spaces ,.. __.".. .t,. .
Fill: I . .. _ a. ,.
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued'=-
I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book - Page j and/or Document#
B. Does the site contain a break, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES : NO 0
IF YES, describe size, type and location: .
D. Are there any proposed changes to or additions of signs intended far the property ? YES 0 NO 0
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 overt scree YES 0 NO 0
IF YES, then a No hampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK lcheck all anolicable)
New House n Addition Repdacament Windows Aireration(s) D Rooting n
Or Doors C
Accessory Bidg. r Demolition ❑ Mew Signs [ES Decks [❑ Siding(Ell Other N
Wo
BriefrkW Des r' tigp iliftwd elk fl i t'ezoi v7tI -L
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
addition
6a: If New house and or 3C��E'k1011 LO existing f101d50Dgl-COPYIpVEEE 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
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
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 OR
R(gJCONTRACTOR APPLIES FOR BUILDING PERMIT
Y- I, Ye 1-e 3 33 ; el as Owner of the subject
propert /� p �j � /,(� n
hereby author - IiiititrUC_� St. RAD tkPC-
to =•y�.'ehaif, in all matters relative to work authorized by this building permit applio ion
/.! nor Date ii
1fQ,11, y',44-L s',;`iH Ne- r•;• fr- `».?ems t`g '1 ,itnG 2.
A-44 a RA. , v
k me s�AormaR � � 2 aeb/2ff my n-ss" 6' information
and belief.
Signed under the pains and penalties of perjury.
M A LL.it.) C1 1K t CZ-o-c.t zN_
Print Name011,1) /
Stgnat ef9rrt2risgen Date
SECTION 8-CONSTRUCTION SERVICES
3.1 Liconsad Consiructicn S,uee.'vissorrI:�^r CC /q� r�,., ,,p Not Applicable EE 4
name ofnlame of nems H lderH !der:Mr MAUR'r-r W v{{. 4 utc 1L c rte— r 9 ( 6 L�C
�j (/-'VkCdref S� , ✓N r . I h/ License her
iff - .Kc. r : . • a U �Je)
Ad.ress F'plrab Date
//%a• A_-_-• iff-. ILeD,� - -Cie`J "7
S• ature Telephone
9.Reaistered Home Improvement Contractor ___-__ Not ApplicablefliicJ £
Company Name Registr ion Nu�eer
5 1t,5 ,�,�J� 1/1S"/8
Address Exit hon D e
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...Y, E No E
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occunied DweWnes of one(1) or two())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, Sirth 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,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-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 He'
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 f W orkers' Compensation) and Chapter 153(Liability of Employers to
Employees for Injures not resulting in Death)of the Massachusetts General Laws Annotated,vou maybe 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
nen The Commonwealth of Massachusetts
t 73 ]Depaiteftsegt of Indythtriel Accidents
r � , yr
'i r� 11 ll Office ofI Investigations
r , � 609 Washington Strset
ix .zzd�
Bost ; 13L4 i92111
n www.marsagov/dsaa
Workers' Cunuapeuusaduom 1[msunrsnee Affidavit Builders/Contractors/Elks laiclansalnunthers
Applicata lmfformaituom Please Print Leann,
.----
Name (Business/Orgarnwfior✓Lvdividual): ,4Wµ CE- ( ;. <tre—( ,---1 ft-
Address:
C
Address: y5 — j26, -77— S°r /ST: b -
City/State/Zip:.eV, Za "Lk O I 0 0 Phone #._ a — o8
Are you an employer? heck the appropriate box:
Type of project(required):
1.17 I am a employer with 4. n I am a general contractor and I
,,,,,,---,,,111 employees (full and/or part-time).* _ have hired the sub-contractors 6. ❑New construction
2 I am a sole proprietor or partner-
_ listed on the attached sheet, 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in anyact employees and have workers'
capacity.
comp. insurance.: 9. E Building addition
[No workers' comp. insurance
required.] 5. ❑ We are a corporation and its 10. Electrical repairs or additions
3.7 I am a homeowner doing all work officers have exercised their 11.P Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such
tContraemrs that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entitles have
employees. If the sub-contractors have employees,they must provide their workers'camp.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
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.
Ido hereby certify um r the vain and penalties ofperjmy that the information provided a17'ye is tr e and correct.
OA 10
Si• amre: iit 0 • i aLI�L'L Date:
Phone#: -I - ',eV
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 Nosthamptona �
• rS
FAF, FF
K
ryry � '219 d hll t s 1Q C]
[i FPj �6,( DTPARTKENT OF BUTTE= INSPECTIONS t; 1
212 Main Street o Nome` Building
.Northampton, MA 01060 r ,)
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER ErIMPTION 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 pour), a rouoh 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)
I 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 c40, 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: ;7/ W4, WV/ u&. R\� . 0 S
The debris will be transported by: HAURI C ki Req.
The debris will be received by: ‘k1_LC.y � �j f 6JG
Building permit number:
Name of Permit Applicant I� ALPZiG� ckt�t t •
i, /49 l /�t- At ,
Date Signature of Permit Applicant