23B-069 (10) File#BP-2018-0467
APPLICANT/CONTACT PERSON CLAUDIO GARRIDO
ADDRESS/PHONE 140 NASH HILL RD HAYDENVILLE (413)268-9052
PROPERTY LOCATION 114 SOUTH MAIN ST
MAP 23B PARCEL 069 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
CLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: ENCLOSE EXISTING CdVEREDPORCH TO MAKE NEW STUDY ALTER EXISTING
HALF BATH-NO CHANGE TO ROOF OR FO ION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 89458
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved ,V 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: § 3 5C1 ?- 3(A) (7
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
Demolition Delay
al </t-7
Signature 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 NorthamptonStatus of ermit:
of Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
' r Room 100 Water/Well Availability
�r r 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 Map R3333 Lot 0& l p�
Unit
114 South Main Street, Florence, MA 01062 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Alexandra Porter 114 S Main St,Florence MA 01062
Na a(Print) Current Mailing Address: 646)221-9062
Telephone
ur
2.2 Authorized Aqent:
�I�1J Dl
1:40 WdM,,, �1 -al ,V1tiU,tact,��w>.�, lM A—
Name(Print Current Mailing Address:
�r� �►3 Zfn�' a 2
_ S
Signature ',Teleprfone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 4,000 (a) Building Permit Fee
2. Electrical (b)Estimated Total Cost of
1,000 Construction from 6
3. Plumbing 1,000 Building Permit Fee
4'e S-: pro
4. Mechanical(HVAC)
5. Fire Protection 500
6. Total=(1 +2+3+4+5) 6,500 Fcheck Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: e►en �fl/+AIr,Ck ZaP> 9.3 1013LIl7
Building Commissioner/Inspector of Buildings Date
alexscottnyc gmail.com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING ALL 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 20,301 sf 20301 (same)
-Frontage 117.47 ft 117.47 ft(same)
Setbacks Front 46.5' 46.5'
Building Height 20' 20'
Bldg.Square Footage 2344 11.5 0/" 2455 12%
Open Space Footage %
(Lot area minus bIdg&paved 16,1101 79 79
of Parking Spaces 3
A. Has ever been issued for/onthe site?
NO 0 DON7KNOVY YES K }
|FYES, date issued:
IF YES: Was the permit recorded atthe Registry ofDeeds?
NO 0 DONTKNOW YES 0
IF YES: enter Book Page and/or Document#
��
B. Does the site contain mbrook, body ofwater Vrwetlands? NO ��� 0]N7 KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained '�� Obtained /—� Date Issued:
\_~� v^~/ '
C. Doany signs exist wnthe propert ��y7 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 0 NO
\FYES, describe size, type and location:
E Will the construction activity disturb(clearing, gradingexcavation,orfilling)over 1acre nrioitpart ofocommon plan
that will disturb over 1acre? YESK��) NO (��
��
|FYES,then uNorthampton 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
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[Z] Siding[0] Other[❑]
Brief Description of Proposed Enclose exist.covered porch to make new Study;Alter existing half bathroom.No change to roof or foundation.
Work:
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes x 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?
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 well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, 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.
Print Name
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.11 Licensed Construction SuyerNdso : Not Applicable 0
Name of License Holder: Claudio Garrido License Number
CS-089458
Address Expiration Date
140 Nash Hill F�� Hayqpnville MA 01039 08/24/2018
Signature Telephone
(413)268-9052
Not Applicable 0
9.Regis-t-er;d Home Improvement Contra I
Company Name Registration Number
10
Address Exp1ration Date
Lfiq
,4 �-Telephon
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,.--� ;1< . No...... 0
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
JV
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information J� Please Print Legibly
Name(Business/Organizationiindividual): (;; 0
Address: T
City/State/Zip: V Phone #: C�I Are you an employer`'Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
mployees(full and/or part-time}.* have hired the sub-contractors
2.7`�`�am a sole proprietor or partner- listed on the attached sheet. }
P� � ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp. insurance. g• ❑ Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
officers have exercised their 10,F] Electrical repairs or additions
required.]
3.❑ I am a homeowner doing all work right of exemption per MGL I LR Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers' 13.0N Other
comp. insurance required.] --i
*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 their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance far 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:____MT
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 insura�e coverage verification.
I do hereby certify under4e p ns d penalties ofperjury that the information provided above is true and correct.
Si nature: J `j Date; o
Phone#: AA
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
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street e Municipal Building
Northampton, MA 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation ("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: �fj ph 01--) Est. Cost:
Address of Work:- 44 0 U, Al 41 el oto
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
Job under$1,000.00
Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
(C)
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building fib~
Northampton, MA 01060st�y. .-C``
Debris 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.
The debris from construction work being performed at:
(Please print house number and street name)
Is to be disposed of at:
't
Vom ?:�'tq(' t -
( lease print harne arW location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
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PORTER PORCH ENCLOSURE 114 SOUTH MAIN ST.
FLORENCE, MA 01062
DATE:OCT.30,2017
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