16D-016 (4) 185 NORTH MAIN ST BP-2019-0692
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16D-016 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Porch Repair BUILDING PERMIT
Permit# BP-2019-0692
Proiect# JS-2019-001126
Est.Cost:$7890.00 0
Fee:$65.00 PERMISSIONIS REBYG TED TO.
Const. Class: Contractor: Lic se:
Use Group: DALE HAWLEY J. 048
Lot Size(sa.ft.): 18164.52 Owner: COCCOL GREGORY &
Zoning:uRB(loo)/ ApRlicant. DAL V67-3149
AT. 185 NORTH A
Applicant Address: Insurance.
P O BOX 273 41
HUNTINGTONMA01050 ISSUE O 2/13/20 8 0:00:00
TO PERFORM THE FOLLOWI O REMOVE EXISTING PORCH DECK, FRAMING
AND SET OF STAIRS AND REBUIL A TO ISTING SIZE
POST THIS CARD SO IT IS VIS FRO HE STREET
Inspector of Plumbing Inspector irin D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Deuartment 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:
FeeTyye: Date Paid: Amount:
Building 12/13/2018 0:00:00 $65,00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2019-0692
APPLICANT/CONTACT PERSON DALE HAWLEY
ADDRESS/PHONE P O BOX 273 HUNTINGTON (413)667-3149
PROPERTY LOCATION 185 NORTH MAIN ST
MAP 16D PARCEL 016 001 ZONE URBO00)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
NCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REMOVE EXISTING PeRcP DECK,FRAMING AND SET OF STAIRS AND REBUILD
ALL TO EXISTING SIZE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 055048
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
Demolition Delay
Q Rae 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 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 Plotisite Plans
Other specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 P o Ee This section to be completed by office
C e�t � t Ce Map Lot Unit
DEC 7 2018 7 / Q Zone Overlay District
/7 Elm St.District CB District
N IP'AUTHORIZED AGENT
2.1 Owner of Record:
RP a rOCcID I u� �tfs .too--Al m � ale CeAXC. i4
Name rintj �r— Current Mailing Address: C
Telephone
Signature
2.2 Authorized Anent:
Da\e-- L (A)k 16 , o
Name(Print) Current Mailing Address:
3Jyq
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building r7 910 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) 7 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
�' Le- 0 DAL6_-s!)rn0c-ryag(, AL o CoAl
SECTION 8-CONSTRUCTION SERVICES
$.1 Licensed Construction Supervisor: Not Applicable ! D
Name of License Holder: o C-S- D
License Number
Address O�0 d Expiration Date/
Signatu T ephone
9.Registered Home Improvement Contractor: Not Applicable !
t>03e%S, L C 11/173a
Company Name Registration Number
96 . 90X 3
Address Expiration Date
Telephone '46
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,?C,.. ! No...... !
/JO C
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition New Signs [m] Decks Siding[O] Other[CA
Brief Description of Proposed
Work: `� S� (9 �5
Alteration of existing bedroom Yes _No Adding new bedroom Yes _ No
Attached Narrative Renovating unfinished basement Yes _�C_No �
Plans Attached Roll -Sheet lair)__ 1-ft9 d r,2'' <
6a.ff 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
s Owner f the subject
property
hereby authorize
AQ�
to act on my behalf,in all matters relative to work autho6z6d bi this building permit application.
of Owner Date
1, as Owner/ thonoge
,01&ent reby declare that the statements i formation on the foregoing application are true and accurate,to the best of y
and belief.
Signed under the pains and penalties of perjury.
,�� � 1 �-�
Print Name
Signature of Owner/Agent Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
U1www.mass.gov1dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Apgficant Information Please Print Leyibl
Name (Business/Organization/Individual): U e.`' Ci
Address:
En , _�p��_a2-`3
City/State/Zip: Phone#: 2 —Uz—? - A l4 9 ,
Are you an employer?Check the appropriate box:
Type of project(required):
1. I am a employer with IQ employees(full an or part-time). ]. New construction
2.M I am a sole proprietor or partnership and have no emp oyees working for me in 8. El Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition
10[]Building addition
4.[:]1 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.: 13.(❑Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14''F''Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.] G e
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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 state whether or not those entities have
employees. If the sub-contractors have employees,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: n i 12 tA-1V Ss&--/4J
1 �
Policy#or Self-ins.Lic.#: X253`0t0)g ift Expiration Date: 5 ,ga� q
Job Site Address: 29.S A e
I, S :43_5J, F1eAP ye-e,MA City/State/Zip: ,F)e rl°Ner-1 M 1q
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 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 certify nder the pains and penalties of perjury that the information provided above is true and correct.
Signature: ( Date:
Phone#: LC Ce 7 ' /4 ct
I
ficial use only. Do not write in this area,to be completed by city or town official
ty or Town: Permit/License#
uing Authority(circle one):
Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
Other
ontact Person: Phone#:
City of Northampton
Massachusetts
DEPARIXINT OF BMZDIPG IPSPECTIC KS �'•
212 Main Street •Municipal Building
Northampton, MA 01060 ®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:
(PI ase print house number and street name)
Is to be disposed of at:
rl
V LLC'
ri(11Y1,
(Please print ame and location o f ility)
Or will be disposed of in a dumpster onsite rented or leased from:
Compan Name and Address
Signatur _Permit Applica or Owner Date
If, for any reason, the debris will not be di osed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.