39A-063 (4) 69 LYMAN RD BP-2020-0228
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:39A-063 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2020-0228
Proiect# JS-2020-000378
Est.Cost:$7000.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: THAYER STREET ASSOC INC 045159
Lot Size(sg.ft.): 7013.16 Owner. LEVITT SAMUEL W&ELLEN L GOLDSMITH
Zoning:URB(100)/ Applicant: THAYER STREET ASSOC INC
AT: 69 LYMAN RD
Applicant Address: Phone: Insurance:
8A COATES AVE (416)665-4018 Workers Compensation
SOUTH DEERFIELDMA01373ISSUED ON:8/22/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE ROOF THAT GOES FROM MAIN
HOUSE OVER GARAGE
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 SiLlflature:
FeeType: Date Paid: Amount:
Building 8/22/2019 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
�� Department use only
,, ►. r City of Northam c1v tato of Permit:
Building Dgpar��C-
r urb ut/Driveway Permit
212 Mai Strom ewer eptic Availability _
Room 100 ' ? 2 Z� ater/ ell Availability
Northampton MA 1 obu T Set of Structural Plans
hone 413-587-1240 ax 13-587- C ass
--��' p ' F�,t}Ilt?�r�'IP�PF �C?OUSIte. IanS_ --- _
nFaT o T a°.n�joN. her Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION g 4 e3-0 )- "
1.1 Property Address: This section to be completed by office
Map .?,,7/4 Lot Olt J Unit
� q LY�dti Sf��rco-�
O / O(,O Zone Overlay District
Elm St. District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 1 �/ 1
h'l o f, to q �XhO-1 s f/GG% Ad0,I&A
ID/a�1 .
Na rint i Current Mailing Address:
Y13 - S 3 7-0.1I Q
Telephone
Signature
2.2 Authorized (ent:
6"oafc s �ye S. Dccrf;e'fd* AIA
Nam Current Mailing Address:
01 8
Signature JvTelephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building � (a) Building Permit Fee
7
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) jIqD
5. Fire Protection
6. Total=(1 +2+3+4 +5) 0 C-0 Check Number
This Section For Official Use Only
Building Permit Number: DateIssued:
Signature: 8-ZZ-zo
Building Commissioner/Inspector of Buildings Date
dr'tw @ + s4 rfe, f aa60ctgfc51 coh,
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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 Department
I,ot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
# of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW ® YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW ® YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW O 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 O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YESO NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, excavation, 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 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [Q Siding ff�:]] Other[[:I
Brief Description of Proposed
Work: JR r- rooAq jL U oeI -',-oA /naihhOVSC Oue-y gq�ucl G .
Alteration of existing bedroom Yes � No Adding new bedroom Yes L, No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existinq 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
I, S a rh U CG V l 71 f as Owner of the subject
property
herebyaLdhorize ; 0
to act onbeJhalf, in all lativ t rk authorized by this building permit application.
Signa�eoOwnerDate
V lr art o.4t as h/Authorized
Agent hereby declare that the s ements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the"pains and penalties ofperjur .
V"r r d
Pri
- a - �
Signature of /Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: / Not Applicable ❑ O
Name of License Holder: V C r)-,Oyl !� Q r ri r~N Y ti S 0 !Y,5-/S /
License Number
C'oalc ,5 / t r- S. e-r fc1, /Llf1. �r373 091 - 03 - a0
Address Expiration Date
�i3 �-�� s- oc
SignatT ph on
G zs
9. Registered Home Im rove ent Contractor: Not Applicable ❑
7-/?QV-cr Site-e{ /� SsoCiQt�S 1'��. /P/o 3 .s
Compan Name Registration Number
Address Expiration Date
Telephone y/3-G GS- '/0/
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....... IH No...... ❑
The Commonwealth oJ'Massachusetts
02 Department of Industrial Accidents
Office of Investigations
' I Congress Street,Suite 100
Boston,MA 02114-2017
www ntass.gov/dia
«Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
,Xpplicant Information 1 Please Print Legibly
Name (Business/Organization/Individual): -Th�e r - C�f e cj A$S O C i Q 7 t S
Address: g C CQ f e s A ✓e
City/State/Zip: s c,r F : C Phone#: 4113
Are you an employer?Check the appropriate box: Type of project(required).
1.9 1 am a employer with -14) — 4. ❑ I am a general contractor and 1
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for in any capacity. employees and have workers' g E] Building addition
[No workers comp. insurance comp. insurance.
required,] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 1 I.[] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.C,Roof repairs
insurance required.] t c. 152,§1(4),and we have no 13.❑Other
employees. [No workers'
comp. insurance required.]
•Any applicant that checks box#1 must also fill out the section below showing their workers'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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employee. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I ani an employer that is providing workers'compensation insurance for n>_r employees. Below is the policy and job site
information.
Insurance Company Name: 141110
Policy#or Self-ins. Lic. #: ISM A 800 960 7_-q-f19-Q O1 "_ Expiration Dater� ] 10
Job Site Address:--i-9__ 49-7 St-'CGT __. -_City/State/Zip:/VO r'yr aipr� ok.AA.010 6 0
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A.of MGL c. 152 can lead to the imposition of criminal penalties of 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 ag . st the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the D for insurance Soverage n!' ation.
do hereby c nder the pai d penal f per' hat the information provided above is true and correct.
i n ture: Date: 8, -
..
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#•
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building
Northampton, MA 01060
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:
9 L y^ d N S r r G C i—[lr 0 r 4110,41,0ld Al /6/¢.
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
7 It,s Ad / oA4 .s Cyhafe
(Company Name and Address)
Signat re of Permit Applica 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.