25A-055 (2) 15 SWAN ST BP-2017-0652
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A-055 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2017-0652
Project# JS-2017-001065
Est.Cost: $145000.00
Fee:$942.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class. Contractor: License:
Use Group: MARK LAN DY 077431
Lot Size(sq. ft.): 8624.88 Owner: MARSHALL DAVID K&MARTHA H CLARK
Zoning:URB(Ioo)/ Applicant: MARK LANDY
AT: 15 SWAN ST
Applicant Address: Phone: Insurance:
P O BOX 61 (413) 625-6999 0
AS H F I E L D MA01330-0061 ISSUED ON:1/10/201'7 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF, REPLACE WINDOWS
& DOORS AS NECESSARY INSTALL ADA ACCESSIBLE KITCHEN, 2BATHROOMS, NEW
ELECTRIC AS NEEDED, INSULATION, ADA ACCESSIBLE RAMP
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 1/10/2017 0:00:00 $942.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0652
APPLICANT/CONTACT PERSON MARK LANDY
ADDRESS/PHONE P O BOX 61 ASHFIELD (413)625-6999 0
PROPERTY LOCATION 15 SWAN ST
MAP 25A PARCEL 055 001 ZONE URB(IOOV
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
��^
Fee Paid A
Building Permit Filled out
Fee Paid
Typeof Construction: STRIP&SHINGLE ROOF.REPLACE WINDOWS&DOORS AS NECESSARY
INSTALL ADA ACCESSIBLE KITCHEN,2BATHROOMS,NEW ELECTRIC AS NEEDED.INSULATION
ADA ACCESSIBLE RAMP
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 077431
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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: §
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
'm. rr- a #for/
Sid : e of B. 'ding Offi Date
* 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 Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
7.1 Property Atltlress. This section to be completedby office
r f s 14/MNST Map Lot Unit
NY V 7T'� A� , Ott(�1� Nc? Zone Overlay District
'V V (" {Elm St District C6 District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
" A CLARK c a'wi0 144KS114a f'}'7fR5N}41.1„, PD 1090in D/O9
Na a rant) /� Cur{gitt]Ings
efiel Telephone
Si.nature
2.2 Authorized Agent:
MARK 4 LAND/ 0$o),/ 6ol,A5HrJEZD /0-,0133?)
4Iame4.2iic) Current Mailing Address:
Al f U,a� Y/3-4,zc-by9y
Sign Lure Telephone
SE ION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Budding ' 95 000 (a)Building Permit Fee
2 Electrical $ Sa& (b)Estimated Total Cost of
Construction from(6)
3 Plumbing/H ffrr `/ 2 9 o&/ 2q o Building Permit Fee
4. Mechanical(HVAC) t Q 7 //_ 9�Q
5. Fire Protection ,[
6. Total=(1 +2+3+4+5) 4 /9t< 00 ,Check Number //dV/
This Section For Official Use Only
Building Permit Number Date
Issued.
Signature.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 b Zoning
This col to be filled in by
Bu ng Department
Lot Size
Frontage _. _. .
Setbacks Front
Side L• _.. R R• __..
Rear __,
Building Height - r
Bldg. Square Footage
Open Space Footage % •
(Lot area minus bldg&paved
parking)
#of Parking Spaces -,
Fill. . . . ...
(volume&Location) _.. _._.. .__.. _.. ...
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW O YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW O YES 0
•
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO V DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:
C. Do any signs exist on the property? YES ' NO
IF YES, describe size, type and location: '
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO t7
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, excavation, or filling)over t acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO ee
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 Win ws Alteration(s) tX Roofing -
Fri---
Doors
Accessory Bldg. El �,a
Demolition New Signs [O] Decks [❑ Siding ID] 0ther[L9f
,,r� 1 n. e r i. • a__ _Brief Descr�iptyon of Proposed 9nii >ireno le/'/(a° 42#760101.5r i 09ne
755 CS cer9/r',/45 at" 4ca 31r4-
Worke/77%O7 r 2 b.f*t �3, new ekdre 0S4 Dak'7/7 so/47540, t Conem, weir ✓
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
ea. If New house and or additi to existing housing, complete the followin
a. Use of building :One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
a Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? •
f. Method of heating? ifi)eplaces 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 Na Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below fished grade
k. Will building conform to the Buildi and Zoning regulations? Yes No.
I. Septic Tank City S er Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. \$izst YRnM\\ t -4" t6 (it*
as Owner of the subject
property
TI,k,-;),
hereby authorize "' '—'
to act on_rii`)e I all mattt�(/r��aahvee ttjt work authorized by this building/pee/rmiitt application.
'"/ k lN"" //t _ l / iik
Signature of Owner Date
!
I. `1kn1A` X asfeauthorized
Agent hereby declare that the tements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the ams and penalties of perjury.
Ril\A
Printy
Signatu of2ndTMAgent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction����1 Supervisor:
� ' A 11ry Not Applicable
�j£[/
Name of License Holder:/-lA 'K , LAUD/ (/5- 07 / 3
License Number
70 BOX (t ! , Aswjcl.O Mm- 013 Ex`//oo/20/st
Address
aY at Yl3-bz5- a'n
Signalur l Telephone
9.Regis ered Home Improvement Contractor. Not Applicable £
,*ea. L-4.UOV °S6Al evYL4 sa&icss 1314,27
Company Name Registration Number
PO 60X Cel 8l/the
�A//ddd�dre��s�s ,A ,f} 2 2 /{ J..yyam� /� Expiration Date
'y[7ff�nap,. 44 1 0/330 Telephone Y73t�4-�offj
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 t• •rovide this affidavit will result
in the denial of the issuance of the bui' . g permit.
Signed Affidavit Attached Yes - £ No £
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owne occupied Dwellings of one(I) or two(2)families
and to allow such homeowner to engage an individual for hire who does of 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 hich he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or • [ached 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 considereli a homeowner.
Such"homeowner"shall submit to the Building Officiaorrn acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the bra E permit.
As acting Construction Supervisor your presenc`` ��^^lisp job site will be required from time to time,during and upon
completion of the work for which this permit is}
Also be advised that with reference to Chapter 152 orkers'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 pe• it.
The undersigned"homeowner"certifies and ssumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local oning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
The Commonwealth of Massachusetts
i?ti @�rt Department of Industrial Accidents
'c7 d l', Office of Investigations
ItI 600 Washington Street
E, -11Boston, MA 02111
'c www.maass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please PrintriLegibly�
Name(Business/Organization/Individual): MARk L,443/p -pts/62.) 'g1f l LV $E v/t
Address: TO/ to ( ./
City/State/Zip: F/� Mit
R
- ogyphone #: its -402C-6951'
Are you an employer? Check the appropriate box: Type of project(required):
contractor and I
1.❑ I am a employer with 4. I am a general6. ❑N construction
/employees (full and/or part-time).* have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet. 7. odeling
These sub-contractors have
ship and have no employees 8. zrnolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.t 9. ❑Building addition
•
required.] 5. ❑ We are a corporation and its 10.(y�'E1ectrical repairs or additions
3.H I am a homeowner doing all work officers have exercised their 11.E s{"1'lumbing repairs or additions
myself [No workers' comp. right of exemption per MGL
yt c. 1 S2, §1(4),and we have no 12.,�,�ie repairs
insurance required.] e 13.Ve ther �91
employees. [No workers'
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 hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must anached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors 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:
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.
I do hereby�c yrYty nder the pains and penalties of perjury that the information provided ab e is true and correct
Signature: x • 1 Date: 11)4 (b
Phone#: 1 - 1025 -6tli
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#:
uns
City of Northampton
t iNassachus=_ttsaz
. l DEPARTMENT OF BUILDING INSPECTIONS
Y rt, 212 Main Street o Municipal Building `6.S
Northampton, MA 01060 '3'61; 3\A'
INSPECTOR
Louis Hasbrouck Chu k Miller
Building Commissioner Assists Commissioner
HOME OWNER EXEMPTION ACKNOWL 7 GEMENT
The State of Massachusetts allows the homeowner the right un r-r 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, " nerson(s) who owns a parcel on which
he/she resides or intends to be, a one or two family dwe ng, attached or detached structures
• accessory to such use and/or farm structures. A person ho constructs more than one home in a two-
year period shall not be considered a home owner."
The building department for the City of Northamp .n wants any person(s)who seek to use the home
owner exemption, to act as their own constructir supervisor, to be aware that by doing so you
become responsible for compliance with s :te building codes and regulations. The inspection
process requires that the building departin(be called to inspect work at various stages, which include
foundation/footings (before bac ill s tube holes (before pour), a rough building inspection
(before work is concealed), insu n inspection (if required) and a final building inspection.
The building department requires the e 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. i
If the homeowner hires othr. trades to perform work (electrical, plumbing & gas) the homeowner will be
responsible to make sure at the trades hired secure their proper permits in conjunction to the building
permit issued, and that t,ey get their required inspections. Failure of the individual trades to secure
•
the permits and inspecti.ns as required can DELAY the project until such time as the proper permits •
and inspections are m.de
I, understand the above.
(Home owner/ esident's signature requesting exemption)
I will call to sche. le all required building inspections necessary for the building permit issued to me.
Date
Address of ork location
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: /5 SWiL1/
The debris will be transported by:14U.$T�� 9iM1Z
The debris will be received by: ,uL 717/CA/ l RECc e rig Eilj 94ftg7iv
Building permit number:
Name of Permit Applicant Mq\cl'(
4130 71.0 tfre-tOf .......111
Date Signat re of Permit Applicant
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CITY OF NORTHAMPTON
$ BUILDING DEPARTMENT
f i ee 171.1M`r I These plans have been revieww�d
And approved. s /ore
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