42 JACKSON 24A-181a j
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Department use only z 4
City of Northampton Status of Permit: 4 OT - it T l
Building Department Curb Cut/Driveway Permit C =13 y
t•212 Main Street Sewer/Septic Availability N l u 1Room100WaterNVellAvailability0zO _f z0
Northampton, MA 01060 Two Sets of Structural Plans z
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans r v rw
o0 MOtherSpecify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING N
SECTION 1 -SITE INFORMATION
1.1 Property Address This section to be completed by office
Z C _j Map Lot Unit
J r
o 1l 6 coo Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
1
AVol_ u 1 crU 14 Z- 1-icc 6Cs84
Name(Print) Current ailin Address:
ty,t N. he-, YVI-4— ZS 1 D Co z)
Telephone ",
Signature T
2.2 Authorized Aaent:
Name(Print) Current Mailing Address
Signature Telephone
SECTION 3•ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost( Dollars)to be Official Use Only
complete 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
Total=(1 +2+3+4+5) Check Number 3
This Section For Official Use Only
Building Permit Number:
Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
e'o4ACasi • 1e (—
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Approved 4/20/20 Louis Hasbrouck
Note: Existing building is non-conforming. Any new structure will
need to meet current setbacks: 20' front, 4' sides and 4' rear.
City of Northampton
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Massachusetts
1. c
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building a `>•
Northampton, MA 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,orconstruction 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.Ifthe homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work: S)b Q 1Q 11}tor Est.Cost: (!h
Address of Work: Z J k4 t S' /l 6 Y a KA4-
Date of Permit Application: 15- r.I Z.a
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 or a building permit as the owner a above property:
Date Owner Xw6 and Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition Replacement Windows Alteration(s) Roofing
y
Or Doors I]
Accessory Bldg. Demolition L4J New Signs [CO] Decks [M Siding[O] Other[t7]
Brief Description of Proposed
Work: 1\ -y 5 x Free
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?
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
as Owner of the subject
property
hereby author'
to act on m half, n all matters relative to work authorized by this building permit application.
Signature of Own Date
fm 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.
Signedun er the pains and penalties of perjury,
eet ire f ea Te -f T-0
Print Name
GL-it-l S `0-Z D
Signature o er/Agent Date
The Commonwealth of Massachusetts
Department oflnduslrialAecidents
a I Congress Street,Suite 100
Boston,MA 02114-2017
s www mass.gov/dia
N\urkers'Compensation Insurance Affidavit:Builders/Contractors/l;lectricians/I'luutbers.
TO BE FILED WITH THE PERMITTING AITTHORItl'.
Applicant Information Please Print LcgjbL
Naive(Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
L I am a employer with employees(full and/or part-tune).* 7. New construction
2.01 am a sole proprietor or partnership and have no employees working for me in g. Remodeling
any capacity.[No workers'comp.insurance required.]
9. ,Demolition3.Ef1 am a homeowner doing all work myself.[No workers'comp,insurance required.]t
10 Q Building addition4.[:]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.Q Electrical repairs or additions
proprietors with no employees.
12.Plumbing repairs or additions
5.]1 am a general contractor and I have hired the subcontractors listed on the attached sheet. 3.[:]Roof repairsThesesubcontractorshaveemployeesandhaveworkers'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#I must also fill out the section below showing their workers'compensation policy information.
I 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
emplovees. If the sub-contractors have emplovees,they must provide their workers'comppolicy number.
I am art ernplGn•er that is providing workers'compensation insurance for my emplovees. Below is the poli(:e'and job.site
information.
Insurance Company Name: _
Policy N or Self-ins.Lic.#: Expiration Date:
Job Site Address: -1 Z J 54 City/State/Zip: /qo r 1 Y wl 'v'`r n4 0 E)
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 ce u der the pacers it p na fperjury that the information provided above is trueandcorrect
Si store: L1 Date: r zZ)
Phone N: 2J Z 31(0
Official use only. Do not write in this area,to be completed by eitl'or town official
City or Town: Permit/License h
Issuing Authority(circle one):
1.Board of Health 2.Iluilding Department 3.City/7'own Clcrk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person:Phone##:
City of Northampton
U:razVry.
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
ft
y 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:
12- 7k-rich 0 til S-. ,
Please print house number and street name)
Is to be disposed of at:
0
P ase print hame an location of facilityl
Or will be disposed of in a dumpster onsite rented or leased from:
Company Name and Address)
Zd Zl1
Signature of Permit Applicant o 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.