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25A-096 (4)
65 SHERMAN AVE BP-2019-0237 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25A-096 CITY OF NORTHAMPTON Lov.-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Cateeorv,Bath reno BUILDING PERMIT Permit# BP-2019-0237 Project# JS-2019-000379 Est Cost $13500.00 Fee, $88.00 PERMISSIONIS HEREBY GRANTED TO: Const.Class: Contractor. License: Use croup: Homeowner as Contractor_ Lot Size(sa. IT): 7884.36 Owner: SPIEGAL HELEN&KELLY SAVOIE Zoni= URB(I00)/ Applicant. SPIEGAL HELEN & KEELY SAVOIE AT: 65 SHERMAN AVE Applicant Address: Phone: Insurance: 65 SHERMAN AVE NORTHAM PTONMA01 060 ISSUED ON:8/2312018 0.00:00 TO PERFORM THE FOLLOWING WORK CREATE BATHROOM IN UPSTAIRS ROOM 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 8/23/20180:00:00 $88.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-0237 APPLICANT/CONTACT PERSON SPIEGAL HELEN&KEELY SAVOIE ADDRESS/PHONE65 SHERMAN AVE NORTHAMPTON PROPERTY LOCATION 65 SHERMAN AVE MAP 25A PARCEL 096 001 ZONE URBH001/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST EN OSED REQUIRED DATE ZONING FORM FILLED OUT /4 Fee Paid Building Permit Filled out Fee Paid Tvoeof Construction CREATE BATHROOM IN UPSTAIRS ROOM 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 TONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed _Other Permits Required: Cub Cut from DPW Water Availability Sewer Availability Septic Approval Bond of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storn Water Management volition Delay 7 / Sigtra[u' Buil ing ffi al Date Note: Issuance of a ing 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 infornation. R parlor wily pto StaWS of Permit Building Depa men Owilbowrivervay Permit AUG 2120118 St et SeweriSepticAvailab Room 10 WaterlWellAvailabllity FP C 10 0 Two Sola of Structural Plans ph DEPT r 7a12401 587-1272 Plot/Stte Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION Pp_ I % 1.1 Property Address: This section to be completed by office Map Lot 416 ex_Unit a106O Zone Overlay District Elm St. District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: // L Neta '�,t�e/ (05 7 IL rAtOA- AVe- Name(Pont) Curre t Mailing Adtlress: _ ,r I Tele ne Signature 2.2 Authorized Agent: 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 S Tw) o 0 (a) Building Permit Fee 2. Electrical I S O O . (� 0 (b)Estimated Total Cost of Construction from 6 3. Plumbing �f / 1 O ooBuilding Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) 3. 5 ate, DD Check Number 2 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissionerllnspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5.DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ [ReplacemeniYtflntlows Alterations) ❑ Roofing ❑ Or Doors ,,��JJ Accessory Bldg. ❑ Demolition ❑ New Signs jOI Decks [q Siding[Ol Other[01 Brief Description of Proposed^, � T /P�� 1, / UnSX/� �-T 6 �'� Or- Work: CCAACC M/77 N L- y_ wn Alteration of existing bedroom_Yes X No Adding new bedroom Yes Y _No Attached Narrative Renovating unfinished basement Yes -A—No u/ Plans Attached Roll -Sheet Sa.If New house and or addition to existing housing, complete the following: a. Use of building One Family Two Famili Other a, a t9"t pdR� rW(f b. Number of rooms in each family unit: Number of Bathrooms Q h 2i 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 fl.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 ,en _PPlp e{` e—1 ,as Owner of the subject property hereby authc e to act on f,in matt relative to work authorized by this building permit application. Signature bi Date I, 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 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 Depurtmenf Lot Size r... Frontage Setbacks Front Side U R: L R: Rear Building Height ' Bldg.Square Footage % Open Space Footage % (Lof area minus bldg&Paved _.. rkin ) #of Parking Spaces Fill: _.. . .. (vdwoe&Locetienl A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW 0 YES IF YES, date issued:' IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW O YES O IF YES: enter Book Page., and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW ® 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 © NO IF YES, describe size, type and location D. Are there any proposed changes to or additions of signs intended for the property? YES © NO O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,a cavahon,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 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable 0� Name of License Holder: _ License Number Add ass Expiration Date Signature Tsiephane 11ROWOM0,000we Immo erflbat'Contractor, Not Applicable ❑ Company Name - Registration Number Address Erpiration 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 pannit. Signed Affidavit Attached Yes....... ❑ No..... ❑ City of Northampton Massachusetts e x DEPARTMENT OF BUILDING INSPECTIONS 212 Main street • Municipal Building Northampton, MA 01060 sr'Yp.. iii 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:Lf the homeowner 4 hasd contracted with a corporation or LLC, that entity must be registered. Type of Work: Ar, I-Do 13A Est Cost:A3.SOD Address' of Work 1ry5 Sk --C!!� Ade- /U�&X Q Date of Permit Application: V D I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): 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: Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I e a for udding permit as the owner of the above property: yDae Owner Name and Signa City of Northampton Massachusetts x DEPARTMENT OF BUILDING INSPECTIONS 212 Main Stmat •Municipal Building Q1, g O4 c NorNa ton, MA 01060 YyY'yj\'�6 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: (05 5k-ea-W-C' Ade, (Please print house number and street name) Is to be disposed of at: � ) ri 11eu R, CGuGI�VLC' (�Ple Se print name a d location off ility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) -- // V, Y/ /—� '3 Z'�/ aO I� Signatureermi A plica 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. \ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.govldia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information I ' Please Print Legibly Name (Business/Organization/Individual): Ave, Address: (05 _' to e-cyVLLt,r� � /I City/State/Zip:/t)d f�(LVw 1`?L4' /" 1 Phone #: 2)Oq Are you an employer?Check the appropriate box: Type of project(required): L[:]I am a employer with employees(full and/or pal time).* 7. ❑ New construction 2.❑I am a sole proprietor or panncnhip and have no employees working for me in g, Dg Remodeling any capacity.[No workers'comp.insurance required] 3J�r(tl am a homeowner doing all work myself [No workers'comp.insurance counted I t 9. El Demolition 4'— 1 am a homeowner and will be hiring contractors to conduct all work on my property. ]will 10 E] Building addition re that all contractors either have workerscompensation Insurance or are sole II.❑Electrical repairs or additions proprlc ma with no employees. I2.Q Plumbing repairs or additions 5❑l am a general contractor,and l have hired the subcontractors l isted on the attached toper 13 ❑Roof repairs These subcontractors have employees and have workers'romp.insuran 6.❑Wc arcacorporadon anditsoticcrs have exemiscdthern,litofcxcmptionper MGL, 14.❑Othef 152,R oat),and we have no employee.[No workers'comp.insurance required.] -Any applicant that checks box k1 must also till out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and darn hire outside contractors must school a new outdocit indicating such. tContnetm that cheek this box most a d ehed an additional shad showing the name at the sub contractors and state whether or not those entities have cope,, as, If tis subcontractors have employees,they must provide their workers'comp.pol icy number_ I am an employer that is providing workers'compensation insurance far my employees. Below is the policy partial,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 imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine 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. I do hereby certify an er t pains and penahies of perjury that the information provided above is true and correct. Signature: Date' 9-0f j 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#: