29-351 (10) 40 AUSTIN CIR BP-2019-1372
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-351 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeory: ROOF BUILDING PERMIT
Permit 4 BP-2019-1372
Project# JS-2019-002210
Est.Cost:$3500.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group; JDR BUILDERS 184755
Lot Size(sa.ft.): 13590.72 Owner: RONALD BUSHEY
zonine: Applicant.- JDR BUILDERS
AT.- 40 AUSTIN CIR
Applicant Address: Phone: Insurance:
P O BOX22 (413)665-7587 WC
WHATELYMA01093 ISSUED ON.6/5/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.BUILD SMALL ROOF OVER EXISTING DECK
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector or Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House N Foundation:
Driveway Find:
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 Sienature•
FeeType: Date Paid: Amount:
Building 6/520190:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2019-1372 O `/'
APPLICANT/CONTACT PERSON BUSHEY RONALD 1&LOUISA A TRUSTEES I{lam.
ADDRESS/PHONE 40 AUSTINCIR FLORENCE n
PROPERTY LOCATION 40 AUSTIN CIR '� / "
MAP 29 PARCEL 351 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid h
Building Permit Filled out WIN
Fee Paid
TvrawfConstruction, BUILD SMALL ROOF OVER EXISTING DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included;
Owner/Statement or License 184755
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
Z�� L- 5-2019
Signaturk of Building Official Data
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.
1
Department use only
CityCity of orthamp p C/''+ Lae
fa artm nt R ECEp it212InS[reeSewerlS m100er Northarli n, MA 0 060 MAY- 3 Se nsFax 3-5 7-1272PIOUSite DEPT OF BUILDING( Othe 5p
APPLICATION TO CONSTRUCT, TER,REPAIR,RENOVAlf OR DEMOLISH A OON�,E OR TWO FAMILY DWELLING
A
SECTION 1 -SITE INFORMATION —1' 'I -L7-�-
1.1 Properly Address: lit, This section to be completed by office
Map_ _ Lot 3 6-1 Unit
&"e C-rl\ai otdt'9- Zone Overlay District
Elm SL District CS District
SECTION 2-PROPERTY OWNERSHIP/AU HORIZED AGENT
2.1 O ner of Record:
\ '
Na (P t) urrent Mailing Address:
Te�pphone
Sig re AA
2.2 Authorized Anent
A►o-ec kr POO Po z z w -r 6, /li 0107S
Name(Print) j Current Mailing Address:
u
yi? 37q
Signature T epMne
SECTION 3-ESTIMATED CONSTRUCT( COSTS
Item Estim' d Cost(Dollars)to be Official Use Only
cpm I ad by ermitapplicant
1. Building 3(;Do (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing v Building Permit Fee
4. Mechanical(HVAC) � 'I
�S
5. Fire Protection _
6. Total=(1 +2+3+4+5) Check Number /7
This Section For Official Use Only
Building Permit Number: Dale
Issued
Signature:
Building Commissioner!ln;,pactor of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
�n
Section 4. ZONING ALL Ire nation 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
Fronta e �
Setbacks Front
Side L:--4, R L: R:
Rear _._.
Building Height
Bldg. Square Footage
Open Space Footage -
(Lot arta minus bldg&paved L.
parking)
#of Puking Spaces - -
Fill:
.Le @ Location
A. Has a Special Permit/ ariance finding a er been issued for/on the site?
NO O DOIIjT KNOW ' YES O
IF YES, date issued: yy
IF YES: Was the permit Feyyyyyk,,E,,,,,��,,,o,,rded at the Registry � ds?
NO O NT KNOW 0 ES O
—__ XConsew
IF YES: enter Boo Paged/or Documentlfi j
B. Does the site contain a L"r k, body of water or wetlands? ONT KNOW O YES O
N
IF YES, has a permit ben or need to be obtained from tCommission?
Needs to be obtained O Obtained Ossued. L I J
C. Do any signs exist on tho.Iroperty? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed ch.mges to or additions of signs intended for the property? YES O NO
IF YES, describe size, ty{+e and location: ,f�
E. Will the construction activity 4-turb(clearing,grading,lavation,or filing)over 1 acre or is it part of a common plan
that will disturb over 1 acre?S., YES O NO IZ0
IF YES,then a Northampt,: rm Water Management Permit from the DPW is required.
�ktfy4�`
4 Y'
SECTION 5-DESCRIPTION OF PROPOSE.WORK Icheck all applicable)
New House ❑ Atltlhlon Replacement MNotdows Alteration(s) ❑ Roofing
Or Doors 12 1
Accessory Bldg. ❑ Demolition ' b New Signs [ Docks [Q Sliding[DQ
[ Other[
Brief Description of Proposed ■ Q� I� 7r`^-II [[out ov!r P/4.s J,7
Work:
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.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? w
it. Proposed Square footage of new constrtlliclion. _Dimensions
e. Number of stories?
a
t. Method of heating? FirepV s or Woodstoves Number of each
g. Energy Conservation Compliance.�,f�Massiheck Energy Compliance form attached?
h. Type of construction _70.1
i
I. Is construction within 100 ft.of wetlands'_Yes No. '[a construction within 100 yr. floodplain_Yes_No
j. Depth of basement or cellar floor below ishad grade
0g
k. Will building conform to the Building and7Zoning regulations? Yes No.
I. Septic Tank_ CitySewer Private well City water Supply
SECTION Ta-OWNER AUTHOR17ATION.10 BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, .5 as Owner of the subject
property
(�/�qj�
hereby authorize If X t KY S
to ad on my behal Inafters r t authorized by this building permit application.
Signature of Owner l
Data
1, �r f h 1 2 oSJ as OvmerlAuthodzed
Agent hereby declare that the statements anti information on the foregoing application are true and accurate,to the best of my knowledge
and belief. --
Signed and r the pains and pe les of peA.
m
Print Name f
A►«..1« Ron y - s- �- iq
Signature of OwnedAgem i ab
. q �
f
SECTION 8-CONSTRUCTION SERVICES'.:
8.1 Licensed Construction Supervisor: II Not Applicable ❑
Name of License Holder: If X.2� 1C �d 't/ e
,/� License Number
Po 22 W �iaky 1 "�' vlv9j ; [- 21- 20 ?Q
Adtlm^ r Expiration Date
c{13 374 5_j� f
ign Lure Tele one
9.Realstered Home Im revement Cont r. Not Applicable ❑
G IgLf-?S— —
Company Name Registration Number
TDR Q (Jars 4 nC . � q- 2
Address ! �/i, Expiration Date
Pp G� (,✓�o'�l/ spa G1e9eephpne y13 37VSa
SECTION 70-WORKERS'COMPENSATIO INSURANCE AFFIDAVI j' .G.L.e.152, §25C(6))
Workers Compensation Insurance afdavitst be completed and subAitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building p.. mit.
Signed Affidavit Attached Yes....... No...... ❑ --
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City of Northampton
Massachrsatts A=s3 s'c<a
0
D5PANT� OF BUIL.i ING INSPECTIONS
212 Main Stoat • Municipal Building
p Northampton, HA 01060
AFFIDAVIT
Home ImprovemenfrContractor Law
i- Supplement to Permit Application
The Office of Consumer AffairsBusiness Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improv ents or renovations on detached one to four family homes.Prior to
performing work on such homes, ntractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires the"reconstruction,alteration,renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addltQ 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.
Nate:If the homeowner has conActed
with a corporado +r LLC,that entity must be registered
Type of Work: Kcaf 6J£ ` Est.Cost: Z,� �—
Address of Work: SrZ� Ct.
i
Date of Permit Application: -
I hereby certify that:
Registration is not require or the following reason(s):
_Work excluded by la (explain):
_Job under$1,000,001 -
_Owner obtaining owp milt(explain):
Building not owner-occupied ..
Other(specify): !
f
OWNERS OBTAINING THEIR OWN PERMIT OR ENTEVG INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONI74CTORS FOR APPLIC- LE HOME IMPROVEMENT WORK ARE NOT
CCESS
ELIGIBLE FOR AND DO NOT HAVE ATO TRE ITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A. SUCH OWNERS ALSO ASYJME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NL*T PAGE FOR MORE INFORMATION.
Signed under the penalties of per :
I hereby apply for a building pcmdt [he ent of the r:
18y 7 S^S
Date Ctractor Name HIC Registration No.
OR: r
Notwithstanding the above notice,;;hereby apply for a building permit as the owner of the above property:
� ;la
Date O ner Name and Signa
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City of Northampton
Massachusetts
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DBPARTNBNT OF BUILpZNG INSPBCTIONS
212 Iain Street • N icipBl Building
Bortlwas pton, IN, 01060
Y
Massachusetts Residential Biding Code
Section I IO.R5.L2
Homeowner: Person(s) whown
u
a parcel of land which he/she resides or intends to reside,
on which there is, or is inte d to be, a one or m amily dwelling, attached or detached
structures accessory to such; a and/or farm strudkures. A person who constructs more than one
home in a two-year period s l not be considered-a homeowner.
Section 110.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 7 CMR 110.R5, provided that if a homeowner engages a person(s)
for hire to do such work, the ch homeowner shall act as supervisor.
Such homeowner shall subm to the Building Official, on a form acceptable to the Building
Official, that he/she shall beIsponsible for all such work performed under the building permit.
As acting Construction Supeicor yourpresence nthe job site will be required from time to
time,duringand upon comp ion of the work for hack this permit is issued.
Also be advised that with reIf cc to Chapter 15 .(Workers' Compensation) and Chapter 153
(Liability of Employers to P loyees for injuries not resulting in Death) of the Massachusetts
General Laws Annotated, y ay be liable for person(s) you hire to perform work for you
under this permit.
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City of Northampton
Massachusettsp6.
p DEPARTMENT OF BUILDING INSPECTIONS
212 Nein Strout oN ieipel Building
NorthaS ,tun, He 01060
Debris Disposal Affidavit
In accordance of the provisions MGL c 40, S54, I acrc.'.owledge that as a condition of the building
permit all debris resulting fromconstruction activity�.overned by this Building Permit shall be disposed
of in a properly licensed solid W a disposal facility, a -defined by MGL c 111, S 150A.
!! a
The debris from construction w0 being performed at:
(Please print house number and street name)
Is to be disposed of at:
s
Ur.1leY RecYC1
(Please print name and location of facility) 'yyouu
1p
Or will be disposed of in a durnVer onsite rented or l +esed from:
Iderf T1-
(Company Name and Ad(gg ss)
1
Signature of Permit Applicant or,Owner Date
W
If, for any reason, the debris wiot be disposed of as indicated, the Applicant or Owner shall notify the
artment
Building Depas to thenIllation where the debris will be disposed.
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�\ 6The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Stre Suite 100
Boston,MA 14-2017
r: www.mass ov/dia
Wil.rkers' Compsensatin Insurance Affidavit:Rpilders/Contnctora/Electricians/Plumbers.
TO E FILED WITH THE PERMITTING AUTHORITY.
Applicant Information ��� .� n T Please Print Leeibly
Name(Bminess/ ontholividudll:
Address:
City/State/Zip:_ MA. hone#:
Are you an employer?Check the appropria , ox:
Type of project(required);
/' o.
L�.Lemacmployer withlar employes(Poll end/orped-time).• 7, ❑New construction
7.0 lam a sole propnetorm partnership and have an employees working forme in $ Ld p�Aemodeling
any capacity.[No workers'comp.inst rowe required.]
7.71 am a homduseardoing all work myselfANo workers'comp.imumtKc required]' 1 ❑Demolition
cb 10❑Building addition
4.[]]em a hommwnm and will be hiring conhadon o conduct all work ce or operry. 1 will
re thin all canrcactors eiNd have woe�ers'mmpcasauon insuranceor}sole 11.❑Electrical repairs or additions
proprietors with no crrgtloyces. lf$
Jfss11 12. Plumbing repairs or additions
5.❑The a general contrnetor e e 1 have employees
have
workers'
listed on Ne�.imched shed. 13 E]Ronf repairs
Theo sub-wnoa<tas have employees erf herc workers rump.insurance.¢'
6.❑We are a corporation and its officers hex xereised their eight of exemption per MGL c. 14.❑Other
157,¢I(4),and we have no emploYecs.[ workers'comp.insurance required.]
Any applicant that checks box N must also fill Qat the seed..below showing their workers'der,so itim policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then him outside contractors must submit a new affidavit indicating such.
lContractors that check this box must touched an additional shed showing the time of Ne sub<untmdom and state,whether or not those entities have
employees. If the subcontractors M1avc employe j,they must provide their workem'comp.policy number.
I am an employer that is providing sea ers'rompensadan,insurance for my employees. Below is the policy andjob site
information.
1 ,.r1,
Insurance Company Name: pG' I LS-
Policy#or Self-ins.Lie.#:� ( 0 0�/7! �/-(� Expiration Date:---
Job Site Address: r/J N L�r`�1, ;, City/state/Zip: T(�iK%J�'L rkT'Th VQOL
Attach a copy of the workers'competpation policy dedarano ge(showing the policy number and expiration date).
Failure to secure coverage as required Mader MGL c. 152,§25A i criminal violation punishable by a fine up m$1,500.00
and/or one-year imprisonment,as well civil penalties in the fo of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this tatement may be forwardc to the Office of Investigations of the DIA for insurance
coverage verificatiot.
I do hereby cerdfy m r th p ns au enalties of perjury that the information provided above is true and correct.
;t
nature: f/ Date: S _ / 9
/
Phone#: -/
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Official use only. Do not write in thus 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 S.Plumbing Inspector
6.Other
K
Contact Person: jj Phone#:
yo Fh 5r C/rCle
oe\ eXxfnyfPr;nt
12
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1,L 11
Dost Gam`+",ou1
� Ptt P � Pay c.AA&fa�