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16C-013 (6)
File#BP-2020-1150 APPLICANT/CONTACT PERSON ALAN LEONE ADDRESS/PHONE 200 BOARDMAN ST BELCHERTOWN (413)563-3431 PROPERTY LOCATION 272 SPRING ST MAP 16C PARCEL 013 001 ZONE URA(100)/WSP(100) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction:_CONSTRUCT 3 BAY GARAGE WITH STORAGE ABOVE New Construction Non Structural interior renovations Addition to Existing Accessoa Structure Building Plans Included: Owner/Statement or License 60627 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 TSewer 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 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 of MGL 40A.Contact Office of Planning&Development for more information. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Streets Sewer/Septic Availability Room 100 `64), 2 Water/Well Availabilit �� y Northampton, MA 01060 4 % Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify s� 60 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVK OR j5EMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION I. 1.1 Property Address: This section to be completed by office A 7�_ S P k1 n 6 S+ Map lX Lot /v / 3 Unit F1O(Z)1rV'( mph 0(06a- Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: jo" L 7Z 40,061 7'� Name rint) �4 Current ailing Ad I/ �j I IVA //A7K Tele on Signa ure r " 2.2 Authorized A ent: rl N Current Mailing Ad' s: Si a ure 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 .� Oav (b) Estimated Total Cost of -� ° tConstruction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= 0 +2+3+4+5) '7,9- ©0r . Check Number 10 This Section For Official Use Only Building Permit Number: 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 �, , 0(o FI c!'S V Frontage ( 3 1 Setbacks Front Side L: R: L: -� R: Rear Building Height Bldg. Square Footage % I �'o Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces C Fill: volume&Location A. Has a Spe at Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW O YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW Q YES o IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained © , Date Issued: C. Do any signs exist on the property? YES © NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO E) IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,ex vation,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 F-1Addition F7Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors M Accessory Bldg. Ed Demolition ❑ New Signs [0] Decks [0 Siding [p] Other[a Brief Description of Proposed Work: C C: O.5I RUC+ -1 G A f' 6c. W 1+ S'to RAGE R nv141 Irl 60 vdF Alteration of existing bedroom Yes t 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 I, r as Owner of the subject property hereby authorize to act on my behalf, n all afters reI76 work autho ' ed b this building permi applica on. MOO Signatur of ne Date as Owner/Authorized Agent hereby d clare 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 penal'es onerjury. Print m W Signature o Owner/A _ Date pLAO PAGE PZ� ' . �a tl- M Z r Qb N 4L �. o sw a� .r Amt 1 6C..0!0204 5x l P N .254 F�Y SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction ��Supervisor: y, Not Applicable ❑ Name of License Holder: Y—► t1 , ] Co _!c _ LS' 06 06 1,7 License Number bot,R9 MAr% St 13 VIcHC,,: ic:rA rAA- 01007 s 30- aC),)� Address Expiration Date W � `(13 - y6$ 5q)l Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date '100 C D m 1✓1 be IC HP✓1}(JcvA Altelephone -1173-5-63 -3y-1 U to07 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....... d No...... ❑ City of Northampton Sys ' ' sic Massachusetts DEPARTMENT OF BUILDING INSPECTIONS y 212 Main Street •Municipal Building yr a t 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: t' is Y1 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: (Company 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. The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): fi Address: c 1�L)1112 ° M� � City/State/Zip: 16 Q I C 1JPa t'u u'&t (Y)Pt 01007 Phone#: 113 6 3 3 Are you an employer?Check the appropriate box: Type of project(required): 1.[3 I am a employer with employees(full and/or part-time).* 7. �ew construction 2.�am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 ❑Building addition 4.[:]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.❑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.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.F1 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. 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: bk '.E' — Date: Phone#:LI 13 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/Liccnse# 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#: