42-043 (6) 669 WESTHAMPTON RD BP-2017-0579
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block:42-043 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-2017-0579
Project# JS-2017-000941
Est.Cost:$30000.00
fee:$195.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor License:
I/se Group MARK SONDE 169228
Lot Size(su.Rim): 25047.00 Owner: JOHNSON FRANCIS&LUCY HARTRY
Zoning: Applicant: MARK BONDE
AT: 669 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
205 PARK ST (413)535-9529 O WC
EASTHAMPTONMA01027 ISSUED ON:I0/26/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:2 BATH REMODEL, TILE, BATH FIXTURE,
ELECTRICAL FIXTURES
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 Or 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 10/26/2016 0:00:00 $195.00
212 Main Street,Phone(413)58742 Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File&BP-2017-0579
APPLICANT/CONTACT PERSON MARK BONDE
ADDRESS/PHONE 205 PARK ST EASTHAMPTON (413)535-952_9 0
PROPERTY LOCATION 669 WESTHAMPTON RD
MAP 42 PARCEL 043 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT .' _ . e T1ON CHECKLIST
•-LOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ,.�•j
Fee Paid
TvoegfConstruction: 2 BATH RE,MODE -T BATH FIXTURE.ELECTRICAL FIXTURES
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 169228
3 sets of Plans/Piot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOQMATION 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: L
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
D- clition De
f jr age rs
Sig : of Building )ff-'al 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 ofpemiC
Building Department Curb Cut/Driveway Permit
4A ,, 212 Main Street Sewer/Septic Availability
\U Room 100 WaterMSIIAVaeability
Northampton, MA 01060 Two Sets of Structural Plans
hone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
d„ Other Speedy
. -PLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOUJSH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
(pbCj 1x155 t 4UAMP,.}131U t fatg7, Map Lot Unit
,.k.,,C>17--SCE t M4 Zone Overlay District
Elm St District CB District-
—
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
Cr,4, rail 6140%4
yuo i-A C 4Y
—÷-1211.1•41>`() (a.6a9 4,j Ffess: AMj-rjGTtl Z,L'� rrh'cc�eF^srs
,�i e(RV— Cu��t(ent Mailing Address- ,2
Telephone
Signature
2.2 Authorized Agent
qa,, -L'--- --,C)F J0r1 —Pisc,pc S7 FAsrwAM Pi74-1
Nemo(Print ----�.�—` Current Mailing Address:
044hs4_.. $ 52x1-7 n !:.
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by pest applicant
1. Building (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.(I +2+3+4+5) --3(:), no 6 Check Number D i(Q C,) "' /9J
This Section For Official Use Only
Building Permit Number Date
Issued:
Signature:
Building Commissioner/inspector of Buildings Date
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To incomplete information
111111111.11111.11111 Required by Zoning
This column to be ills in by
Building Department
iffiell11111.111111111111111a
Setbacks Front
1111.11111
Side
Rear
®--=
Open Space Footage -®--_
{Leu area minus bldg&paved
.akin_
111111111111111
A. Has a Speciarnit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW 0 YES 0
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 0—'1ONT KNOW O YES O
IF YES,has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES a NO O
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? YE; O NO lJ
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 0 Addition 0 Replacement Windows Alteration(s) 0 Roofing 0
Or Doors ❑
Accessory Bldg. 0 Demolition ❑ New Signs (pi Decks ❑ Siding Ell Other((gam--
Brief Description of Propa,
Work: 2 ..cu 2/1460E4- t It IC .
Y .�N ,r-Mill lam, ,Ec:tt . +-."r UVr ES
Alteration of existing bedroom Yes Co Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
aa.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
g. Energy Conservation Compliance, Masscheck Energy Compliance form attached?
h. Type of construction
1 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 CONTRACTOR APPLIES FOR BUILDING PERMIT
I, I r*./97UC(S 4 To!4`7(i S'D,N , as Owner of the subject
properly
i
hereby authorize Ac.-Ire. e5 AID E
to act�I '' all matters relative to work authorized by this building permit ap licatio .
Signator of Owned- Date
I, d t.ib ,as Owner/Authorized
Agent hereby Clare that thelTatements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under e pains;•• •-nalties of perjury.
AC-N-b F
Pont Name .
_est 4.1b ' (tri - 0-
Signafu ' orMt-/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
ono of License Rolaw:_„.H PrIZIC to T>F CS Okr115' ,
License Number
Address Expiration Date
VV" era(�i L413 -57.1 - Zi7L
Signature ` Le_phone
$. Home Improvement Contractor Not Applicable 0
k NbE (A1467 tzvciiu gtOg22.g
company Name cis;-r Registration Number
2c8,
2c8 ikz-11-� 41 �`Ji a.-%i- t ' r
Address Expiration Date
Telephone U 13 7?\"r-?17t
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152,h 250(6))
Workers Compensation Insurance affidavit ust be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildi 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 or 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 be
responsible for 011 such work performed under the bufdina permit,
As acting Construction Supervisor your presence on the job site will be required from lime 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,Stale and Local Zoning Laws and State of Massachusetts Cental 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: Lk, 9 1AI rst v4AmOTtf gh,
The debris will be transported by: ,-, r (r„s CT Wert cQ
The debris will be received by: Vitu,c' lomat yr cr .. t
Building permit number \
Name of Permit Applicant kArk g
C z4 l b ✓y17ar-C1P
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
j
. fi�� Office of Investigations
:
_ ;� l Congress Street,Suite 100
' _+ Boston,MA 02114-2017
* • wwwmass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you employer?Check the appropriate box: Type of project(required):
1.
am employer with Z 4. ® I am a general contractor and 1 G. New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. age-modeling
ship and have no employees `these sub-ccontractors have 8. 0 Demolition
workingfor me in anycapacity. employees and have workers'
P tY 9. a Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 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
Other
employees. [No workers' 13.0 -
comp.insurance required]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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 state 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: 1,2p•of;co en C,
Policy#or Self-ins. Lie. #: 7:F29D • • Expiration Date: k 3'-\ L
Job Site Address: Lb C_ lf1/4.1FSairlA Ert a S City/State/Zip:4-j.j— r3/ El..la 016 b2.
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 u the pains and penalties of perjury that the information provided above is true and correct,
Signature: 7a4,. en7+.tk/ Rate: \ [5 -e.,iC4 '
Phone#: `1 t 3 a 2J1 -
tap
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
d.Other
Contact Person: Phone#t