18D-010 (5) 3 COOKE AVE BP-2017-0634
GIS#: COMMONWEALTH OF MASSACHUSETTS
May:Block: 18D-010 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPAIR BUILDING PERMIT
Pennit BP-2017-0634
Project# JS-2017-001028
Ea Cost: $1200.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BELISARIO BURT 100030
Lot Size(so.ft.): 14984.64 Owner: SERRANO GIL
Zoning:URB( 00)/ Applicant: BELISARIO BURT
AT: 3 COOKE AVE
Applicant Address: Phone: Insurance:
31 EXETER ST (413)222-2914
EASTHAMPTONMA01027 ISSUED ON:
TO PERFORM THE FOLLOWING WORK:DRYWALL CEILING
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:
FeeTepe: Date Paid: Amount:
Building $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0634
APPLICANT/CONTACT PERSON BELISARIO BURL
ADDRESS/PHONE 31 EXETER ST EASTHAMPTON (413)222-2914
PROPERTY LOCATION 3 COOKE AVE
MAP 18D PARCEL 010 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT /
Fee Paid +-_J
Building Permit Filled out
Fee Paid
TpeofConstruction: DR WALL G
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 100030
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ION 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
�- klith' le -y• /J 7
jii0000V err
Signature of Building 0ffi '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.
pepartmentuse--holy"City of Northampton StatUsof Perms 2A t .
Building Department Curb':Cuf/Dnyewey Permit
212 Main Street $ewerlSept(Cbveilabildy
/< J Q Room 100 Water/Well-Availability
Northampton, MA 01060 Two Sets ofStmdursl Plens
\ — phone 413-587-1240 Fax 413-587-1272 PloU$de Plans
\--.<'!_.----< Other Spe*\tptiy.CATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: 3 Cryo ei This section to be completed by office
IV ortI rrp FDG 0(06° Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
' L 14IVaizei $erKaho 3Cooke
Name(P i nof Current Mailing Address'.
/ 1 f e A1 Telephone
lir nature •�Yrl i/f :
2. •uthorized Agent: Adel-
.../
•
dt,i� ulr1 31 % BY L5/ ylon tka 0/c7=r
Name(Pram) / Current Mailing Address- ✓
♦_ r— N(}-227 —29 /U
Signature/r% Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building O (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) Check Number / yq Q Or
This Section For Official Use Only
Building Permit Number: Issued:
Date
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
Lot Size . I I. __.. _.. _. I I _.... _. I
Frontage [ _.___ I 1 _ _I 1 i
Setbacks Front f J I__._ I _1
Side L:I_ _ I R,I l Lr J RI _....I I ]
Rear 1 1 1 -
Building Height r li
Bldg. Square Footage - % - i
C__ 1 I I
Open Space Footage , % — _
(Lotr areaminus bldg&roved L ( I_ I l I .
parking)
#of Parking Spaces 1 _1 --! I J
Fill: I Il
(voliimc&Location) --. _.._. ll _ _
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOWco— YES Q
IF YES, date issued:[._ 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Bookr
_. ] Paged __.il, and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ei DONT KNOW O YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained Q , Date Issued: ii
C. Do any signs exist on the property? YES O NO 0------
IF
/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 0-----
IF
-/IF YES, describe size, type and location: I '
E. Will the construction activity disturb (clearing, grading,excav 'on,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.
I
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House n Addition ❑ Replacement Windows Alteration(s) n Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [D Siding[p) Other ir
i
Brief Descrri tionf Proposed
Work: e,itif , dfd Lk/ ' 142/11t, el
Ateration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes _No
Plans Attached Roll -Sheet
pa. 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
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
X. 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, ,as Owner of the subject
property
hereby authori - a I b ei ,)6 t/1/
to -- on t.r . iiiro n . . 'atters relative to work authorized by this building permit application.
di11,
5
Sigp Lure of Owner Date
e
1. e /( sun -0 U.v-6 ,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.
Sed under the pai and penaltie of perjury.
eJ( Y 13 ga r
Print Name
_ /03 / /2v/7
Signature of Owner/Age - D e
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Suu ervisor: �m /� Not Applicable ❑
Name of License Holder- �V�h b ° 63u r t /00. 030
LicenseN tuber
/ e 55� . ' ai, gft)vi yna 0 (0 z-1 l01-3 � zo1-7
Address Expirati n Date
21(3 - 2-72-7J)2`) ly
Telephone
/O';a,'l ) !Isar(obLkrt g yahoo .Gom
.9. -egistered Homelmprovy�ent Contactor: - Not Applicable El
6ctr(-'S (tong u4' Hrr�6 � /65619
Company Name Registration Number
- an i 3 Dome, wveme41 Und C7 e 3//0 / l 8
Address Expiration Date
3 / (Jyel� Q -ry/�,� 0 Telephone 143 T2.2> NA/
_ Kf7 !>!o 23.
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
I in the denial of the issuance of the buildinguingpermit.
Signed Affidavit Attached Yes yy No 0
11. - Homer 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,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 all such work perforated under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,duringand upon
completion of the work for which this permit is issued.
Also he 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 tie 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: T 0 rety
The debris will be transported by: Baylis 69,7wr = Cfi'6 C
The debris will be received by: Vp t fec/ cqe,c
Building permit number:
Name of Per ' Applicant C 6e1 i5Dr 4-0 0 t w
Date 00/3 //2-6/6 Signature of Permit Applicant
The Commonwealth of Massachusetts
r Department of IndustrialAccidents
Office of Investigations
i —
n1 Congress Street, Suite 100
•
' — Boston, MA 02114-2017
-AL
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /' // �jP�^Please Print Legibly
Nallle (Business/Organization/Individual): }��ZVI ) (�Q61ef[7/G11I /IL C(/ GI
Address: 3/ />�C" S /
City/State/Zip: Z i i &Vt 17, 010 27 Phone #: 4/3 – 2-2 2 - -2-9
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 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.W I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. employees and have workers' 9. n Building addition
[No workers' comp. insurance comp.insurance?
required.] 5. ❑ We are a corporation and its 10.❑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' comp. right of exemption per MGL
12.n Roof repairs
insurance required.] t c. 152, §I(4), and we have no
employees. [No workers' 13.❑ Other _
comp. insurance required]
*Any applicant that checks box#1 must also Ell 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.
tContractors 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. lithe sub-contractors have employees,they must provide their workers'comp.policy number.
I inn an employer that is providing workers'compensation insurance for my employees. Belmp 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 a aur the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DI f ' surance coverage verification.
I do hereby certify a er the pat and penalties of perjury that the information provided above is true and correct.
Signature: ) —7 - Date: //7102V° _
Phone 4: L1/7 — 22 2 7 9�4
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
6.Other
Contact Person: Phone#: