43-003 408 WESTHAMPTON RD BP-2017-1304
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:43-003 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Bath rend BUILDING PERMIT
Permit# BP-2017-1304
Project# JS-2017-002161
Est. Cost: $13746.00
Fee: $89.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RONALD LAMAGDELEINE 8067
Lot Size(sq. ft.): 26397.36 Owner: ECKSTEIN JOHN ALFRED&PHYLLIS KLEIN
Zoning: Applicant: RONALD LAMAGDELEINE
AT: 408 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
112 LAUREL HILL RD (413) 527-8169
WESTHAMPTONMA01027 ISSUED ON:5/1I/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL 1ST FLOOR BATH ALL FIXTURES TO
REMAIN IN SAME LOCATION
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 5/11/2017 0:00:00 $89.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck- Building Commissioner
File Id BP-2017-1304
APPLICANT/CONTACT PERSON RONALD I.,AMAGDEI.,EINE
ADDRESS/PHONE 112 LAUREL HILL RD WESTHAMPTON (413)527-8169
PROPERTY LOCATION 408 WESTHAMPTON RD
MAP 43 PARCEL 003 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICAT ON CHECKLIST
�[�E . OSED REQUIRED DATE
ZONING FORM FILLED OUT
V�
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REMODEL 1ST FLOO 'ATH . FIXTURES Q REMAIN IN SAME LOCATION
New Construction
Non Structural interior renovations
Addition to E 'stint
Accessory Structure
Building Plans Included:
Owner/Statement or License 8067
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
Demoli 'in Delay
/Iesditt d s///
Sig o'.uilr g • rcial 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 40k 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
1.1 Property Atltlress''' 1 ,�,,//� P U' T1his section to bt mzo/.leted by office
'o& u)eST�)i,oror "'cad Map 1 Lot 1 Unit
`fc'e telt• /44 0' '/2 Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
1(7 Owner of Record:
t =0"-Ey kctit)cog Lid)s&/3111el..e>o•1 �,4 6 CArr /414 Cita_
Name(rri^ Current Mailing Address:i/�y
y n Ciet:1 Telephone
Signa . -
2.2 : orized A!ent:
�
.. c S e NL y/Z L/Q U / /
n eL �/ // ✓�i� tort7FmvrL.rin»
Na e(Print) Current Mailing Address: 0/0 27
Bl� a//3 37y 3716
Si. ature 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
?z/v. 49
2. Electrical (b)Estimated Total Cost of
jg30,D O Construction from(6)
3. Plumbing Building Permit Fee �--
300. 00
4. Mechanical(HVAC)
MAY — 9 '210
5.Fire Protection �/�7
6. Total=(1 +2+3+4+5) /37//6 nit Check Number e� g . Np9
This Section For Official Use Only
Building Permit Number Date
Issued:
Signature:
Building Commissionermnspeclor of Buildings
Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: / Not Applicable !
Name of License Holder:Fob) I , mrag del etNe CS- oOa p[.7
U License Number
)/ 2 I nu el /-hi/ /2v we nnizo 1m.* oia z7 z//y/7o/A
Address� Expiration ate
.ent <�,(/oOLx. y/3 _ 7y 727s�
Signature (/ Telephone
9.Registered Home Improvement Contractor: Not Applicable
� )
ln... L1nvn/ #'fr. /o/ Toy
Company Name Registration Nufiber
/17 / AU We Z. /1/// /21-) ele9j/
A70./
Address // - Expiration Date
L✓e2..5 1M l /.'l,. inn 0/077 Telephone y/3T)` 1?9
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
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes.V<! No .
11. - Home 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 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,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House n Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [IZ) Decks [0 Siding[CI] Other[OJ
Brief Ddption of Proposedrr
Work: Xe M ame / / frAv« iist/+soK'H A/l Ft Tvttrr Te ala741N /ice-C/IM e Lecnra‘f'
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. 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?
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 well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
" tneN F.K l
I,
,as Owner of the subject
property
hereby authorize �Or Lam O 5191? /1a--
to act on my b half, in all tters relative to work authorized by this building permit application.
ter /y/a,/
Signature of r JJ Date
I. (/[�p/N ttnn/� 1 IA-'-- ,as Owner/Authorized
Agedt hereb°dare th f he 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.Print a
Signa re of /Agent Date
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: 708 Ldr27L .f i fb ce y s o too z
The debris will be transported by: ev ` Awipyldan,.
The debris will be received by: (/y, 1/7 P(r y c 1e7
Building permit number:
Name of Permit Applicant 22 Ll9ntA davc
//2c/7 < v 714l lGne-
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of IndustrialAccidents
=' T/!=Ci Office of Investigations
=1 �te 7 Congress Street, Suite 100
• "ig— Boston,M4 02774-2077
�� www.mass.gov/dia
Workers Compensation InslranceAffidavit: Builders/Contractors/Electridans(Plumbers
Applicant Information Please Print Legibly
Name(Rosiness/orgxnizetlon/Inaividnap: rib rid I p4n,A-1.�e/e
A
Address: 112 [ ,Cct U
City/State/Zip:(,,7ej4 m ' C+.' M Alt O/ce 7 Phone#: 1�/ij y /S3
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑ 4.I am a employer with ❑ I am a general contractor and 1 6. ❑New construction
sw
ployees(full and/or part-time).* have hired the sub-contractors
2. am a sole proprietor or partner- listed on the attached sheet. 7. lirkemodeling
ship and have no employees These sub-contractors have g, [' Demolition
working for me in any capacity. employees ab harewcrkere
[No worker& comp.insuracomp.insurance.t 9. El Building addition
nce
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 I1.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
I2.0 Roof repairs
insurance required]t c. 152,61(4),and we have no
erj oyes [No works& 13.0 Other
comp.insurance required.]
'Ary ypli cat Mat daksbox#1 must also fill out the section balm showing their wakes carpe eaim poll of infamstim.
t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicatingsuch.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the submtlraotors a.e9ryloyea,they mast providethdr votes comp.policy rumba.
I am an employe that is providi ng works& compensation insurance for my employees Below isthepd icy and job ate
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a ropy of theworke-& 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 ce under a pains and penalties of perjury that the information provided above u true and correct
Signatunk !'� /54,1,11./.1.w. Date: .6//70/7
Phone b: dy/2 ?7y ?75'1"-
Ofcial 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#: