24D-033 29 Winter St Bldg Peront app 2014-05-06File # BP-2014-1155
APPLICANT/CONTACT PERSON FORREST DEVINE
ADDRESSIPHONE 20 HARTLAND HOLLOW RD GRANVILLE (413) 214-8629
PROPERTY LOCATION 29 WlNTER ST
MAP 24D PARCEL 033 001 ZONE URB(lOO)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Type of Construction: CONSTRUCT 16 X 20 BEDROOMIBATH ADDITION
New Construction
Non Structural interior renovations
__ Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 95779
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON TillS 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 ProofEnclosed ____ _
Permits Required:
Cut fromDPW ___ Water Availability ___ Sewer Availability
___ ~'-I:"'-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
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 ofMGL 40A. Contact Office of
Planning & Development for more information.
Winter5t
~ ,-q
48.0"
24'-0" 12'-0" ------------~--------------+
J\) ~---------------------+6----.
24'-0"
16'-0"
1 4-CW45
/\/\I~~~.
r-
r---.~
I BEDROOM
I QUEEN
~ -I
First Floor
7'-0" f 1
Scale: 3/16" = 1'-0"
1
~
-
5' lJ
'" ~
j II i
~
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~ ~
WlntBrSt.
Northampton
eeann I Jtectura ~-.. ~ T ... _
413.lI1.f141Ci L:114114
12
12
drop exterior walls, raise ceiling joists
use 2x12 rafters
?~, ~rw/l..J-tIf>
12-21 I.AlSu/44wN ltV
~~S
)a. S ~ rN ~rl,~,
bL~~------~~----------------------------~~~t~F7~~o,~
a "u) l~'l.. CAQJl.L~ ~M.-
Section
Scale: 1/4":= 1'-0"
WfnterSt.
Northampton ~c.nn
rchltectural
i Drafting &
Tom~ ............
4124114
of Northampton
Department
2 Main Street
Room 100
MA01060
L-2!~~~!iW~ill~] -1240 Fax 413-587-1272
APPLlCA'nON TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 • SITE INFORMATION I
1.1 Progem Address: Tbls section to be completed by office
-2/1 wlNferSkee{-Map Lot Unit
Zone !)verIay DlstriGt
EImSt. DIStrict (:8 Distrlc:l
SEC'nON 2 • PROPERTY OWNERSHIP/AUTHORIZED AGENT I
213 Q!!nlr 2f Bl!i2rd:
lrtf t 7Zos~ 27' W / N.f-.er Sf-reA!!. t-
N~~ CuJTellt Mailing Address'3-S<ir£ 6~l 'Vc.
Telephone
Signature
2,2 Autborized Agent:
20 lIa'-fk~ I(ol!e>l-V fo (Tt:f2J-Deo l /U2.-/Zo(
~d Current Mailing Address: G I't!l: I"Ivll ! t:. M!T-D(e3-'/
"Y/3 2;/.::',/ f?bZ9
Signature < Telephone
SECTION 3· ESTIMATED CONSTRUCTIONm!
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
L/ ~ CJC7{), -c:>
(a) Building Permit Fee
I 2. Electrical 1(200" C?C"> (b) Estimated Total Cost of
Construction from (6)
3. Plumbing '3 ~C> ,/000; Building Permit Fee
4. Mechanical (HVAC) Z. 600, c;? C> 5. Fire Protection , ... ~,"',-
.. '
6. Total = (1 + 2 + 3 + 4 + 5) 7'<-r; 7VO. Check Number /qr'l YI'/ll?tI-
This Section For OffiCial Use Only I .
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of BUildings Date
Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zolling
This column to be fiDed in by
Bwlding Department
Lot Size
Fronta e
Setbacks Frgm
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minw; bldg &. paved
volume &. Looation
A. Has a Special PermitlVariance/Finding ever been issued forlon the site?
NO 0 DONT KNOW (}Jj YES 0
IF YES, date issued:l __ ~ ____ l
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book pagel~.,~ and/or Document
B. Does the site contain a brook, body of water or wetlands? NO (jJ DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained o Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES o NO t::J
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
IF YES, describe size, type and Location:
E. Will the construction activity disturb (clearing, grading,
that will disturb over 1 acre? YES 0 NO
ation, or filling) over 1 acre or is it part of a common plan
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WQRK {check all applicable)
NewHouse o Addition Roofing ~ Replacement Windows Alteration(s) rt:b
OrDoors 0 ~ ~--------------------------------~--------------------------~
Accessory Bldg. 0 Demolition New Signs [t:l] Decks [CJ SidinsH.B1P Other [Cl]
Brief Descri~n of Proposed r1. ' I
Work: J::;i:;!!..f'/::c.-If, Ie z.t!? V.etJ. rt:rt:Tl'1.
Alteration of existing bedroom ~ Yes __ No
Attached Narrative ~
Plans Attached Roll -Sheet
Adding new bedroom)? Yes _-:-:-_No
Renovating unfinished basement Yes :4 No
a. Use of building: One FamBr:;;;~~~ ____ Other ___ _
b. ______ Number of Bathrooms, ____ _ Number of rooms in each family unit
c. Is there a garage attached?
d. Proposed Square footage of new construction. _____________________ Dimensions _____________ _
e. Number of stories?
f. Method of heating? _____________ Fireplaces or Wood stoves _____ Number of each
g. Energy Conservation Compliance. ____________ Masscheck Energy Compliance form attached? _____ _
h. Type of construction
i. Is construction within 100 ft. of wetlands? No, Is construction within 100 yr. floodplain
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 Sawer __ _ Privata well ___ City water Supply __ _
SECTION 7a • OWNER AUTHORIZATION,. TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
__ No
I, hd
property '"
}JeJ \{)oGK. ' as Ownerofthe subject ...-.-~e<res.f--~eu£.1..(..-rtet;,dMf-G>Fve"""<'\L~S-H~""N INc...
~~...,e~rs relative to work authorized by this building permit application.
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
Date
SECTION 8 • CONSTRUCTION SERVICES
8,1 Licensed Construction Supervisor: Not Applicable 0
Name of Yet"!! Holder: & cr a "S J-D..e () ( "'-'L C> fS-77?
License Number ExfMrari~~
Telephone
;9:ReQisjr!iUlOiDe:lmptOXet!!.nt:Co~tiaCtOr:·:
]2e.t/IrlL-C;n-;;ffvd-ecr.v (A.lC-
Not Applicable 0
IZ-S-t7t?
Company Name
20 Itt/f/~ !!a 110 tV 1Zo1f~ t?/Cl~Z7
_________________ Telephone q/'f 2/'1 f'~??
Address
SECTION 10· WORKERS' COMPENSATION IrtSURANCEAFFIOAVlT(M.G.L. c.152.§25C(6)) I
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 ofthe building permit.
Signed Affidavit Attached yes ....... 0 No ...... 0
The cwrent exemption for "homeowners" was extended to include Owner-oscupied 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, Sixtb Edition Section 108.3.5.1.
Dermition of Homeowner: Person (s) who own a parcel ofland on which he/she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attacbed or detached structures accessory to such use and! or farm
structures. A person wbo constructs more tban one bome in a two-year period sball not be considered a bomeowner.
Such "homeowner" shall submit to the Building Official, on a fonn acceptable to the Building Official, tbat be/sbe sball be
responsible for all sucb work performed under tbe 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 _______________________ _
The Commonwealth of Massachusetts
Departmlmt of Indusirial AcCidents·
OffICe of Investigations
1 Congress Street, Suite 100
Boston,.MA 02114-2017
. . www.mll$s~gov/dia .
Workers' Compensation Insurance Mfidaviti Builders/ContractorslElectricianslPlumbers
Applicant Information . Please Print Legibly
Name (BusinesslOrganizationlIndividual): y~ ~ ~~oI-tO N I ~ Cr
City IState/Zip: W Phoile#:
Are you an employer? Check the appropriate box:
I. ~. I am a employer with ., 7'! . 4. 0 I am a ~eneralcontractor and I
employees (full and/or part-time). '" have.hired the sub-contractors
2.0 I am a sole proprietor or partner-listed on the attached sheet.
ship and have no employees These sub-contractors have
working for me in any capacity. einployees and have workers'
[No workers' compo insurance compo insurance.:
required.] 5. 0 We are a corporation and its
3.0 I am a homeowner doing all work . officers have exercised their
myself. [No workers' compo right of exemption per MGL
insurance required.] t C. 152, § 1 (4). and we have no
employees. [No workers'
compo msurance reqmred.]
Type of project (required):
6. 0 N~:w construction
7. BfRemodeling
8. Demolition
9. 0 Building addition
. 10.0 Electrical repairs or additions
II.O Plumbing repairs or additions
12.0 Roofrepairs
13.0 Other~ _____ _
• Any applicant that checks box # I mustlilso fill out the section below showing their workcrs' 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,
fContmctors that che.:k this box must attached an additional sheet showing the name. of the sub-contractors and state whether or not ~hose entities have
employees. If the sub-contractors haVe emPloyees, they mUst provide their workers' comp; po~icy number: .
1 am an' employer tliat is providblg workers' compensation insurance for my employees. Below is thepolicy and job site
information. ~uranceCompanYName: __ ~cr~C/~6~~~~~.yr~L/~AI~S~& __ r~~~~-= ____________________ ~ ________ -
Policy # or Self-ins. Lic. '___________________________________ Expiration
City/State/Zip: V~.I'S1'piLo AI ,
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secUre cov~a:ge as required under Section 25A ofMGL c.152 can Jead to the imposition of criminal penalties ofa
fme up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the fonnofa 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.
Officilll use only. Do not w~ite in this area, to· be completed by city or town officilll
City or Town: __________________ PermitILicense
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Citylfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.0ther _______________________ _
Contact Phone