24A-216 (2) 23 ADARE PL BP-2017-0862
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24A-216 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit# BP-2017-0862
Project# JS-2017-001455
Est.Cost: $8000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MICHAEL MCKENNA 057009
Lot Size(sq. ft): 13285.80 Owner: BERNSTEIN CHARLES J& WENDY F
Zoning: URB(84)/ Applicant: MICHAEL MCKENNA
AT: 23 ADARE PL
Applicant Address: Phone: Insurance:
209 POMEROY MEADOW RD (413) 527-1266 WC
SOUTHAMPTONMA01073 ISSUED ON:1/18/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:CHANGE WINDOWS FRONT OF HOUSE
**WINDOWS MUST BE ENERGY STAR**
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 1/18/2017 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File# BP-2017-0862
APPLICANT/CONTACT PERSON MICHAEL MCKENNA
ADDRESS/PHONE 209 POMEROY MEADOW RD SOUTHAMPTON (413)527-1266
PROPERTY LOCATION 23 ADARE PL
MAP 24A PARCEL 216 001 ZONE URB(84)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT Fee PaidBuilding Permit Filled outFee Paid
Tvoeof Construction: CHANGE WC/14:_fe9
NT OF HOUSE tfa-
New Construction /A0
Non Structural interior renovations /
Addition to Existing �/1
Accessory Structure
Building Plans Included: ) /V
Owner/Statement or License 057009
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO. RMJ'.ION PRESENTED:
proved 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
f�
Sign. •• . :0011 miat 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 Penna:
Building Department Curb Cut/Driveway Pemilt
212 Main Street Sewer/Septic Availability
Room 100 waterAvell 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
1.1 Property Address: This section to be completed by office
d3 Acicx.cac_e_ Map Lot Unit
k c i- Am 9t0'\ .MH o t0L 0
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
(I V\aJ\CS /nc,+ein �rru—
Name(Print) Current Mailing Address: 5
'_ � f L -_ Telephone
Signature
2.2 Authorized Agent:
Mlcl')O-cca Nc Ke42na_ ("kg V n-f[01 Mec204_.)-R6 `tu_k-htainVto-)
Name(Print) Current Mailing Address:)
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
co
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection it
VO
Total=(1 +2+3+4+5) -� St CKD dC) Check Number d6i
.4) tVO
This Section For Official Use Onty ( 3 2uI7
Date : JAN
Building Permit Number: Issued: •
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition 4Replaceme ndows Alteratlon(s) Roofing
Doors
Accessory Bldg. Demolition New Signs [ ] Decks [ ] Siding[ ] Other[
Brief Description of Proposed �I_
Work: C h��P li)inYAr S �C `� ous.2
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes _No
Plans Attached Roll -Sheet
sa. If New house and or addition to existing housina.complete the followina:
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 Na 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
Cknj lCi Lie-(n S , as Owner of the subject
property
hereby authorize I�A\IC_hno —3, l-{C.KZ flvM0.
to act on my behalf, in all matters relative to work authorized by this building permit application.
SCO Di :3 ';1
s' nature of Owner Date
I- 1 C Yr-La 1 7 Mc Ke_.-1I mC. ,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.
Signed under the pains and penalties of perjury.
Mlchctjj -S McKzrno_
Print Name
.
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.7 Cleansed Conatruetlon SutxMaor: Not Applicable 0
NaIIMALU enae_eider: a._ .. .' l Y`f C S' 06-1 C fOct
License Number
• s P• urs �I d Soot • • ( ( - dOlS,
Address Expiration Date
�.,
Signature Telephone
iskathltaitina Not Applicable ❑
a no
Compare Name n Registration Number
J * MA
• - � a .N t - �`G.' _...
Address Expiration Date
Telephone 41 Sett-
SECTION 10-WORKERS COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152.§25C$))
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 perm0.
Signed Affidavit Attached Yes V No ❑
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 not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 188.3,5.1.
Delinition of Homeowner:Person(s)who own a parcel of land on which heishe resides or intends to reside,on which there
is.oris 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 Officials that he/she shall be
responsible for all such work Performed under the building permits
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 Ratite 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,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: Para re -Thiac�
The debris will be transported by: CoHkc r \-c "
The debris will be received by: \lcaj\e_i_i -RD c1 1
Building permit number
Name of Permit Applicant Micv,�U T3 N cKennot-
i
Date Signature of Permit Applicant
\ The Commonwealth of Massachusetts
Department of Industrial Accidents
=:-. t• Office of Investigations
ip :.
I Congress Street,Suite 100
Boston,MA 02114-2017
'smbw www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leaibty
Name Business/Organization/lndividual): K r , c.i.f.:, -� nYY_l _
Address: 3. 'f icor _ li _ —_ r' sigia , \v`ti Mtn 0t023
City/State/Zip: L----- Phone#: L})3 .S --1 --- id(
Are you an employer?Check the appropriate box: Type at project(required):
I.❑ I am a employer with 4. 0 1 am a general contractor and I
6. Q New construction
employees WI and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
9. 0 Building addition
[No workers' comp.insurance comp_insurance.:
required.] 5. ( We are a corporation and its 10,0 Electrical repairs or additions
officersq
have exercisedtheir11.0 Plumbing
3.❑ 1 am a homeowner doing all workng re Pairs or additions
myself. [No workers' comp. right of exemption per MGL 12❑Roof repairs
insurance required.]' c. 152,§1(4),and we have no 13 ❑�� �}
employees. [No workers'
comp.insurance required.] l-eiTh1,0C.2ly .n-
*Anv applicant that checks box#l must also till out the section below showing their workers'compensation policy inf ation.
t Homeowners who submit this affidavit indicating they ere 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 stat whether or not those entities have
employees. If the sub-centrattms have eaplown,they must provide Nest 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:(3-Ps v4,t1 k'-4 lk ivi tr'O1 t61 IV, /
Policy#or Self-ins. Lic.#: t) (._1vo -7 )(7 el() 1l Expiration Date: 9 ` 7—..), 1 t
lob Site Address: 'ON\bk.A Y t 1\t-t City/State/Zip: 0✓r&lint(✓ii)4 14 L1((,')' )
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 MGT,c. 152 can lead to the imposition of criminal penalties of a
foe up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certify under the pains and penalties of perjury that the information provided above a nue and correct
Signature: •% ! ("
�� � - Date: I - it- I1
Phone#: 413 - ..$'Arl - 1 E l-,
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
I.Board of Health 2.Building Department 3,City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
—
Contact Person: Phone#: