09-009 (6) 508 KENNEDY RD BP-2018-1357
GIS 4: COMMONWEALTH OF MASSACHUSETTS
MV.Block:09-009 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv: Bath reno BUILDING PERMIT
Permit4 BP-2018-1357
Proiect# JS-2018-002406
Est.Cost:$10000.00
Fee:$65.00 PERMISSIONIS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(so.ft.): 68824.80 Owner. VERSON ALAN&PAULA
Zoning: RR(100)/WSP(100/ Applicant: VERSON ALAN & PAULA
AT: 508 KENNEDY RD
ApplicantAddress: Phone: Insurance:
508 KENNEDY RD (413) 586-1348 n
LEEDSMA01053 ISSUED ON:611 912 01 8 0:00:00
TO PERFORM THE FOLLOWING WORK:BATHROOM REMODEL
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 6/1920180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File 4 BP-2018-1357
APPLICANT/CONTACT PERSON VERSON ALAN&PAULA
ADDRESS/PHONE 508 KENNEDY RD LEEDS (413)586-1348 Q
PROPERTY LOCATION 508 KENNEDY RD
MAP09PARCEL009 001 ZONE RR(100)'WSP(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
TyveofConstrue ion, BATHROOM REMO L
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
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 aglition Delay
gignarru—re of Building Offr ,1 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.
i City of Northam
Building Depart nt JUN I i� u�U)ip i
212 Main St"
Room 100
Northampton, MA 108lfPT or ousolucn
Non orv,
phone 413-587-1240 Fax -
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 •SITE INFORMATION
This tweldrift to he man~'byotbw
1.1 Property Address:
sob l�nned� fZd t _unit
e aA S zoa. t
she SL 61,01,401 CB darns
SECTION 2.PROPERTY.OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
A\ om. 16Txv� QIP yvz �� Oyovfi�arAe� db1
Name Pn t) Current Mailing Add sst�r t a
dt��('U\'p�_�.,I)A Telephone G
Signature
2.2 Authorized Agent:
r
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3•ESTIMATED CONSTRUCTION COM
Item Estimated Cost(Dollars)to be Official Use Only
completed by permitapplicant
1. Building 5 0 0 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
♦J Construction from 6
3. Plumbing O O Building Permit Fee '
4. Mechanical(HVAC) �S
5. Fire Protection
6. Total=(1 +2+3+4+5) 0 O Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Budding Co�rnmissionerflnspec1foof Buildings
Dow
Je,w � V
EMAIL ADDRESS
(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Completed. Permit Can Be Barbed Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
d e°RA `ES Building nepamnent
Lot Size
Frontage
Setbacks Front ---' � � n-----'
Side L R:L__i Lf R _j
Rear
Building Height
Bldg.Square Footage % r-
Open Space Footage __ %
(Lot ama minus bldg&yavrd -
parking)
#of Parkin Spaces L
Fill:
.mama&L«aeon
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ® DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book :-
Page and/or Document#1
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES 0
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
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(deari grading..excavation or filling)over 1 acre or Is it part of a common plan
that will disturb over 1 acre? YES O NO
SCA
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED W
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [O Siding 0=1 Othor[a
Brief Description of Proposed 1_
Work: � CiftyVoom ir � `V\ 0 )a L0 \/I
Alteration of existing bedroom_Yes h No Adding new bedroom Yes 2r� No
Attached Narrative Renovating unfinished basement Yes ?�No
Plans Attached Roll -Sheet
"lf:NaW houseand of a-di klOn t0 aXlaklDli ,
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 g.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 Is•OWNER AUTHORIZATION•TO BE COMPLETED':WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ,as Owner of the subject
property
hereby authodze
to act on my behalf,in all matters relative to work authorized by this building pennit application.
Signature of Omer \ / Date
1, A R V\ V(' '1/`S(�� as Owner/Authorized
Agent herebyy d clave tthat 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.
2_V'S U Id
Print Nama
Signature of 0 ner/Agent Date
SECTION 8•CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable]
Company Name Registration Number
Address Expiration Date
Telephone
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... No...... ❑
City of Northampton
Massachusetts
DEPARTrlENT OF BUILDING INSPECTIONS
212 Nain Street • lno ipal Building
North m ton, Na 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 mom than four dwelling units....or to structures which ere adjacent to such residence or building"be
done by registered contractors.
Nate:Ifthe homeowner has contracted with a corporation or LLC,that entity must be registered
Type ofWork:3�!h Y 11 o bA `11e12n br) Est. Cost: 1 0 f f)Q n
Address of Work: S 9 Ere VL K E d� R� F �c E
Date of Permit Application: f.
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 RESPONSIBH.ITES 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:
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for
p a building permit as the owner of the above pro :
U
-1 `4 ^ 1Y3 0.to eVSAto IUAM
Date Owner Name and Signature
City of Northampton
Massachusetts
D AR3 H!r OF BUILDING INSVZ=0NS
313 Nain Street *Municipal auiltling
Northampton, NA 01060 0
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, 1 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:
1769
(Please print house number abtl street name)
Is ttobedisposed of at:
bltl
(Plea print name aMd location o ility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
A \L1�, ,
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.
-C-\ The Commonwealth ofMassachuseus
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
WWorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE PILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/OrganiaatioNlndividual): 1"-F \I).C1. '0✓—V,--, If -
Address:--'S-T1
Address: ST1 � Q Y\ P"A
V,n^
1 it n111:4
City/State/Zip: L'Q eA S /,VA O(aI S 3 Phone f. l 3It 1i
Are you an employer!Check the appolionte box: Type of project(required):
I.❑I am a employer with employees(full and/or pamfirm)• 7. New construction
2,F1 1 an a sole pomnemr or partnersldp and have no employees working for me in g. ®Remodeling
any capacity.]No workers'comp.worries requhed.]
J❑1 am n homeowner doing all work myself[No workers'comp,in.,required.l r 4 El Demolition
4.01. a homeowner and will be hiring cantmctors to cant.,all walk on my properly. I will 10 Building addition
crime thawn contract..either have workerarampensition iusmersommesole I LCAElectdcal repairs or additions
preparation with no emplo,w s 12.0Plumbing repairs of additions
5o 1 am a gdaml e m artmand I have hired the e.b.nuactors listed on the attached she.. 13❑Roof repairs
These sub-wrnradcas have emploand y«s have workers comp.inra
sunce.
6.M We are a.,..it.and to omcem have exemieed their right of exemption per MGL c. 14.❑Other
152,§I(4),and we have.employers.(No workers'comp.iramence requhed]
•A.y applicant that checks box#1 must also fill out the s.it.n below showing their workers'cion ansati.n policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire mands contractors must submit a new affidavit indicating such.
iContructors that check this box most amched an additional sheet showing the name.fthe sm wasaacto ,and slaw whether or not those entities have
employees. If the alb-contractors have employers,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.Lia#: 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 MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprlsediment,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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ido hereby cel fy under the p^''i(1''a sad pufemot es ofperjury that the information provided above is P&ue and cco�rrect.
Simulate (T1/l� \6-1+'N�M Ute Date' \ SLS
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#:
J .
Mau , 'h4 d
I Mi
Mug
Yfll0 t 'd x »
a°' ? I d
zaf
r
" hh,
4 `i
13
ka
a z m to `fi3'
.. } :.:
FII�.
w� i
t
x
c
"� g ti 4°t ��t r a•~ � � a xw
a
000
WOW w
v t3 d �.
SS C � .STNIYl
to,L h�
S+� 4
SK5 Alan and Paula Bath layout Sarah Etteiman
Jan 22, 2018