31A-096 (4) 57 VERNON ST BP-2017-0673
clsft: COMMONWEALTH OF MASSACHUSETTS
Map:Block:31A-096 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGIS I BRED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:KITCHEN RENO BUILDING PERMIT
Permit# BP-2017-0673
Project JS-2017-001101
Est.Cost: $21000.00
Fee:$136.SQ PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: NICHOLAS JONES 066878
Lot Size(sq.K.): 29620.80 Owner: Pamela Lawrence
bourne:URB 100 /WP 48 / Applicant: NICHOLAS JONES
AT: 57 VERNON ST
Applicant Address: Phone: Insurance:
P O BOX 515 (413) 665-7927
WHATELYMA01093 ISSUED ON:11/16/2014 0:00:00
TO PERFORM THE FOLLOWING WORK:KITCHEN RENO - NEW CABINETS, KITCHEN
FLOOR, NEW PANTRY
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/4 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 11/16/20160:00:00 8136.50
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0673
APPLICANT/CONTACT PERSON NICHOLAS JONES
ADDRESS/PHONE P O BOX 515 WHATELY (413)665-7927
PROPERTY LOCATION 57 VERNON ST
MAP 31 APARCEL 096 001 ZONE URB(100)/WP(48)1
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid ( f- Stu
Building Permit Filled out 1
CABINE
Fee Paid
TvofQppstmction: KITCHEN REN -N
neTS.KITCHEN FLOOR.NEW PANTRY
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owned Statement or License 0668t�78
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INP MATION 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:ys
Finding Special PermitVariance*
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
Deu' 'no •e+
'"�Ase
.Z //-/5-7(
r m
Signat dim O' cial - 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 of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sas of sbucturai Plans
phone 413-587-1240 Fax 413-587-1272 PtoVSite Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1,1 PropertyAdrtlresg
Vin { This section to be completed by office
j itrt Jin- Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
I \OLVLA.e . Larev C
Name(Print) Current Mailing Address:
Telephone
Signature
Po 8 n `Os'
/ le .s a JeAR fLtdtlital /4a o 1013
Name(Print) / Current Mailing dress:
• Yr 3 (jt- 712-7
Signature Telephone
SECTION 3-ESTIMATED C NSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building .'p, (a) Building Permit Fee
tato
2. Electrical / /COO (b)Estimated Total Cost of
Construction from(6)
3. Plumbing a /0-00 Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection �
6. Total=(1 +2+3+4+5) I",,j Bet Check Number 581 ' /3. SO
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
;,--- �
Building Commissioner/inspector of Buddiergs Dale ,
N).. 4
psi
Section 4. ZONING Alt information Must Be Completed.Permit Can Be Denied Due to Incomplete Information
Existing Proposed Required by Zoning
This Column La be fiIled in by
Building D partmem
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:�,�
Rear
Building Height
Bldg. Square Footage ^k
Open Space Footage
{LoI area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Specie! Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW Q YES Q
IF YES, date issued:
IF YES: Was the he permit recorded at the Registry of Deeds? �^y
NO V DONT KNOW O YES U
IF YES: enter Book Page and/or Document ft
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 0 YES lJ
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained V obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO 0
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 e
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? YEE O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all a000lcable)
New House 0 Addition 0 Aeplacemenf3indows Alteration(s) ® Roofing 0
Or Doors ��77
Accessory Bldg. 0 Demolition 0 New Signs (pJ C]
rt
Decks ID Siding IQ] Other(
Brief Descrip{{((o of Proposed A�Cid cJ '1..h . new k.I.k. Pico. w negA't'r"y
Work: k'4t,kin of KO uStAliors N,
Alteration of existing bedroom Yes Vk No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes x No
Plans Attached Roll -Sheet
ea.If New house and or addition to existino 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 stones?
f Method of heating? Fireplaces or Woodsioves 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 0. e kq , I (IA .w,�1 IP vs f Z ,as Corner of the subject
pmpeyY / ! YI To-el-LI
IG7n IGS -I o!l<f
to act on my behalf, in all matters relative to work authorized by this building permit application.
SignaNre of Owner Date
f, 1( a S 17rrl,\' , as OwneriAuthonzed
Agent hereby d are that the statements and information on the foregoing application are true and amirate,to the best of my knowledge
and belief.
Signed un
rAhe painand penalties of perjury.
/- i 6 fip J pvli,s-
Pant Name
�. Slit
Signature of Owner/Agent n�/ Date
SECTION S-CONSTRUCTION SERVICES
Icon, a• ee;t cti•n ] :.:rvi-,r: Not Applicable El
Name of License Polder'," '/})iR ('t
. �J � ♦ CS- 0 669 76'
5 Ina A. License Somber
tArN0. • a 5/I 121.711
Address de. r Expiration Date
hid —. 3 -ac- 7y4.7
Signatu e / Telephone
. . =.:1-t:. ..em=. mr.• u:nt ls_n• : Not Applicable ❑
1 sA 5 i i 8'
ComoanvName . e Cht5 nuQrA
t 9I 1� Registration Na bar
. , N " 0 s' O
Address Jty, Expiration a=
Telephone 4 I 1-7f;7
•
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,G.L.c.152,§250(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 A No 13
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner•oceupied Dwellings 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
as supervisor.CMR 780, Sixth hdition Section 108.3S-L
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 la 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
resvons hle 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,Cily 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 150k
Address of the work: 5-7 Verna A AVE-
The debris will be transported by: j is L, L $ T A�
The debris will be received by: VALI get )
Building permit number:
Name of Permit Applicant / Yi 1 k5 Ticruci
„ hjl a
Date Signature of Permit ' 00 scant
The Commonwealth of Massachusetts
Department of Industrial Accidents
_ _
Office of Investigations
_II I— I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /Kiel 4ti Please Print Legibly
Name(iusiness/Organization/Individual):
Address: 17I C5 " 'not Ain A)
City/State/Zip: &44&1 d j4& tO(013 Phone#: tj/3 _ /6i-7g27
Are you an employer?Check lire appropriate box:
Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.VI I am a sole proprietor or partner-
These
on the attached sheet. 7_ Remodeling
ship and have no employees '1"hese sub-contractors have g. ❑Demolition
workingfor me in anycapacity. employees and have workers'
9 Building addition
[No workers' comp. insurance comp_insurance.:
corporation 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 11,0 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
employees. [No workers' 13.0 Other
compinsurance required]
"Any appbaant Wal checks box ft I must also fill OW the section below showing their workers compensation policy information_
Homeowners who submit this atTidavit 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 these entities have
employees. If the sub-contractors have employees,they must provide their workers comppolicy number.
I am an employer that is providing workers'compensation insurance far my employees Relow is the policy and jab 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.
von
Ido hereby certify r pains and�tpenai/Ms ' perjury that the information provided above is true and correct
$ignature ii//!�(l N ..._ Dnte 1/I/7�
b0/ f
Phone#: �/7 "- - 7 '
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.CitytTown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other ,,
Contact Person: Phone#: