24D-088 (12) Department use only
City of Northampton 9 Status of Permit:
Building Departmnt 3 Cur1�Cut[Driveway Permit
l f , 212 Main Street'q, 2��' Sewer/Septic Availability
G i
Room 100 , Water/Well Availability___
- Northampton, MA 0106�' sA� Two Sets of structural Plans
phone 413-587-1240 Fax 413-587-1� �' O Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
v1f s -to rt /lJ-�)cT Gv-ems, -
SECTION 1 -SITE INFORMATION 56'g-c-L Ca `>/ l I a a i'-O tv'l�
1.1 Property Address: This section to be completed by office
Map ���f� Lot v Unit
O `v�
I Zone Overlay District
Etm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(P Q Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
CC� I r
Name(Print) Current Maiirrg Address:
M- "2,
Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (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) 0 0 Check Number
This Section For Official Use Only
Building Permit Number- BP- '?U Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
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
Lot Size _
Frontage
Setbacks Front
Side L:r�------�� R L __J L:.._. _J RL__...-..._f _ L
Rear
Building Height r--j -----
Bldg.Square Footage %
Open Space Footage r-, %
(Lot area minus bldg&paved j
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 O YES O
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 DON'T KNOW O YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading, excavation, or fifling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO O
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 Q Addition Q Replacement Windows I Alterations) Roofing
Or Doors
Accessory Bldg_ 0 Demolition [Z] New Signs Decks Siding[O) Other[01
Brief Description of Proposes
Work: �J �'[� QX� f �c &c,y—, ft�S �
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. 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?
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
1, �� t� K�Q,N as Owner of the subject
property
hereby authorize
to act on beh in all matters relative to work autfrorized by this building peT3'
it a kation.
C) :4 v
Signature.Signatured Owner 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 Nam
4)� k'
rJ1
( � �n
of OwnedAgent Dale
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: r — Not Applicable ❑
< n ►-� (/
Name of License Holder:
p �y License Nuffiber
Addrqw Expiration Date
Telephone
9.geqWqrqg Home knDirovement Contractor: _ Not Applicable ❑
Company Name Registration Number
Address Expiration Date
CTelephone ;Ao A
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..----- No...... ❑
City of Northampton
777
Massachusetts
.,
' L1EP8RTPN:NT OF BUILDING INSPECTIONS y, `
212 Main Street • Municipal Building
Northampton, M8 01060
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.If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: f ifV10cy vgx-y— Est. Cost: dU
Address of Work: (J C7�` 1 S�
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job 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 hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
The Commonwealtk of Manackusem
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
t www massgov/dia
«orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information j, 1 Please Print Leeibly
Name(Business/Organization/Individual):
Address: e:f � -�'C,Q/
City/State/Zip. i r Phone#: C/E
Are yen an employer'Cbeeb the appropriate box:
Type of project(required):
1.❑1 am a employer with employees(full and/or part-time).* 7. E]New construction
2141 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity-[No workers'comp.ins- required-]
9. ❑Demolition
3.1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 Q Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that an contractors either have workers'compensation insurance or are sole 11.[:]Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs
71bese subcontractors have employees and have workers'comp_insurance.=
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[]Other
152,§1(4),and we have no 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.
: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: _
Policy#or Self-ins.Lic.#: 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 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.
I do hereby cernunder the pains and enaldes of perjury that the information provid(ed�above is true and correct
Signature: Date:
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#:
City of Northampton
r, Massachusetts
~ S DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building f *a
Northampton, MA 01060 r'�t ?t,
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:
3.
(Please print house number and street name)
Is to be disposed of at:
C
(Please print rfame and loc ion of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Compafiy Name and Address)
Signature of Permit Applicant 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.
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