32C-224 (34) 79 HAWLEY ST REAR BP-2016-1223
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-224 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2016-1223
Project# JS-2016-002106
Est. Cost: $12000.00
Fee: S 100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DAVID LANE 108477
Lot Size(sq. ft.): 2395.80 Owner: WANG FAMILY TRUST
Zoning: URC(I001/ Applicant: DAVID LANE
AT: 79 HAWLEY ST REAR
Applicant Address: Phone: Insurance:
119 STATE ST (413) 205-9790 WC
PALMERMA01069 ISSUED ON:I/4/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:NEW ROOF
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 1/4/2017 0:00:00 $100.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1223
APPLICANT/CONTACT PERSON DAVID LANE
ADDRESS/PHONE 119 STATE ST PALMER01069(413)205-9790
PROPERTY LOCATION 79 HAWLEY ST REAR
MAP 32C PARCEL 224 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT �
Fee Paid 4/1(10
Buildino Permit Filled out
Fee Paid
TypedConstruction: NEW ROOF
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 108477
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
D-mo ! .
4111,r-
Sign. ure of Building Official 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:
� a r- BuildingDepartment Curb Cut/Driveway Permit
APR
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
cu" _ 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
1.1 Property Address: // This section to be completed by office
9--`Q '/ � Si" glair Map Lot Unit
Aiprtita,^(+^ M4- Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
1(- / frTer4.'eS LLC pa aPK 3V9 /4^, tierrd m4 Sy.
Name(Poop Currentyid Mailin Address:
OOV5
7415� 0
Telephone
Signature Managiw� Me�.lt/-
2.2 Authorized Apent: ✓✓
Dk—V,
i14 as—a;F $ -
Nam Current Mailing Address:
( 3) 9-9//7
Sign tore Telep one
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ; z o o 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 /630 yjf�
This Section For Official Use Only /�
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING AU 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
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage °o
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Findi ever been issued for/on the site?
NO 0 DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Re • try of Deeds?
NO 0 DONT KNOW YES O
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O 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 far the property? YES O NO
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? YES O NO
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 Windows Alteration(s) ❑ Roofing 54
Or Doors D
Accessory Bldg. 0 Demolition 0 New Signs [O] Decks [Il Siding[CI) Other ID]
Brief Description of Proposed frit...,
Work: K)Lw }PDv-k -k NTa aw 2 .5 I SL -&,,, .
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ba.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
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private welt City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING
�PERMIT {.�
T ' cT %t sr. " iL/FieF as Owner of the subject
property
hereby authorize 1 -Dt. -1Z }-.--.wN.(_ -k,cr-vu9._ :' - CCs,iLr ,."-t-S
to act on my be O,in all at ers relative to work authoRzed b/this building permit 1pplication.
Signature of Owner , Date
MIMIIIIII
I, Tho.”,' Cl [ Ira ,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.
Signder the pains and penaltiesiiof perjury.
F--fin-L
Pri
Signature of Owner/Agent r Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Liceff88d Construction
(��Supervis�lor: j Not Applicable 7D
Name of License Holder'. O Vt4� ri 1� L 1
License Ni^her
7/ 11 lg
ExpiratiDate
A. on�
IP_._ • ) .mss ::.97 ?U
Sign.ture T: :phone
9.Renistared Home Improvement Contractor. Not Applicable ❑
nT t /5e36 i
Company Name Re istration Number
1 3-44—ka_ Sk , l } Zn Ir
Address �c "�S Ex ratan Date
ex ( CT 4-.0-vi s..._- s., r „: .'4elephone [-G 9750
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8))
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 1:1
11. -Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or two(2)families
and to allow such homeowner to engage an individual for hire who does riot 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 hetshe 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 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,Cay of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
The Commonwealth of Massachusetts
„— Department of Industrial Accidents
)E-='z /t= 'l Office of Investigations
101``'J-1 1 Congress Street, Suite 100
=k
='_ Boston, MA 02114-2017
difwww mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): _ wt 1--,-."4_,1--,-."4_, .o .� Ntitwl�s
Address: 13-1 I r-k y. 54 .
City/State/Zip: -a I w.e-r t1/4-t A at n G 9 Phone#: Ill 3 - 2_0 5 - 75 0
Are you an employer? Check the appropriate box: Type of project(required):
1, Zi I am a employer with Z 4. 0 I am a general contractor and I
6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. El Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurances
9. ❑ Building addition
required.] 5. 9 We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 1 L❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work
myself [No workers' com right of exemption per MGL
Y p. 12.13 Roof re airs
insurance required.] f c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other o01 ,�
comp. insurance required.]
'Any applicant that checks box#1 must also fill 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.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not hose 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. $
11 � J
Insurance Company Name: L1- 1S1St f T t) ti--1
✓4 ✓Cr.
Policy it or Self-ins. Lic. #4.4)(_ S3 153 8 Lc7 3 3 0 I_S Expiration Date: �3/Z-0 / 701 7
9
Job Site Address: 714 IC,i citeL-1- City/State/Zip: /wo rj'hsr,Oion It IA
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 uunddee he pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone#:
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 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: 7? f1ccw ltd S{rwA
The debris will be transported by: r ,,c
The debris will be received by: Vu_I (�1 P_c_ LAI:-
Building
cBuilding permit number:
Name of Permit Applicant d r. "._v
•
Date Signature of Permit Applicant