24A-255 (8) File#BP-2021-0128
APPLICANT/CONTACT PERSON HANS DALHANS
ADDRESS/PHONE I I CHERRY ST EASTHAMPTON (413)977-6094
PROPERTY LOCATION 25 NORFOLK AVE
MAP 24A PARCEL 255 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
OSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
Typeof Construction: RENO PORTION OF GARAG UN ROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessoa Structure
Building Plans Included:
Owner/Statement or License 101628
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
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.
Rams
The Commonwealth of Massachusetts
m - - (� Board of Building Regulations and Standards FOR
o - t / Massachusetts State Building Code,780 CMR MUNSE
ICIPALITY
X
o Building Permit Application To Construct,Repair;Renovate Or Demolish a 'Revised Mar 2011
a c r—
One-or Two-Pamily Dwelling
o g `� This Section For Official Use Only
5 z �N Building Permit Number: •- Z Date Applied:
m O
n �y
p Building Official(Print Name) Signature Date
Z
SECTION 1:SITE INFORMATION
1.1 Prop'gty dress: 1:2 ssessors Map&Parcel Numbers
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private Q . Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check ifycs❑
SECTION 2: PROPERTY OWNERSHIP'
2.5Owner'of C.01, rUAQV $I DDL—t- N 0?-TR*%4f 71-0N MA 0 l0 BOO
Name(Print) City,State.ZIP.
2�1yDR-rro�Ll� Ay fs=. 14 t3 6Sg gg421 .�►Go'f t'tiK�k.Co 1tiD 4,��. t1�w�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alterations) Addition ❑
Demolition Accessory Bldg.❑ Number of Units Other ❑ S ecify:
Brief Description of Proposed Work2-, t7omf 7
t "
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1.Building $r -�O 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee "
b4t O Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ Q -2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire Ll
Suppression) $ Total AllFe
Check No. heck Amount Cash Amount:
6.Total Project Cost: $ 0 ❑Paid in Full 13 Outstanding Balance Due:
s -7�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supsor License(CSL) t�1 i 6 a Qt,
6 tcense Number ExiliratiolL Date
Ni"X"MN
CSL Hol 11�j List CSL Type(see below)
No.and S eet Type Description
AlUnrestricted(Buildingsu to 35,000 cu.R.)
•T Restricted l&2 Family Dwelling
City/Town.8taic,ZIP M Masonry
RC Roofing Covering
WS I Window and Siding
11 r, SF Solid Fuel Burning Appliances
I Insulation
Telephone mai]addrtss V D Demolition
5 Regist Ho Improvement Contractor(HIC)
RIC Registration E#iratibn Date
ompany ame RIC Registrant Name
07,
c, r
fanlz
freer Email d
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLG.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..........a No..........•O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize C 1 Q
to act on my behalf,in all matters relative to work a tTnzed by this building permit ap lication.
Print Owner's Name(ElectroSi re) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest er the d penalties of perjury that all of the information
4critained in this appl'cation is�tnrueanudiacto to best o my knowledge and understanding.
trot woer's or Authorized Agen ame(Electro-M Signature) JDate
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an opener who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.fr.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed_ Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
i
I
I .
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION
REAR YARD
SIDE YARD SIDE YARD_ _
i
FRONT:SETBACK_ _ d
FRONTAGE________
I � '
. i
I
The City of Northampton
y Building Department
212 Main Street
Northampton,Massachusetts 01060
Phone(413) 529-1402
Fax (413) 529-1433
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance with the.provisions of MGL c40, s54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility as defined by MGL c 111,S 150A.
The debris will be disposed of in:
f
Location of Facility
The debris will be transported by:
Name of Hauler ' �� W� _ — _ _ — _ —
___
Signature,of Applic t: Date:___ _ __ ___. _
I
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.
Anplicant Information Please Print Legibly,
Name(Business/Organizadon/ndividual): ,!a
Address:' 1-
,V-City/State/Zip. � 1 )'kO$one#:
Are you an employer!Check the appropriate box: Type of project(required):
1.0 1 am a employer with employees(frill and/or part-time).* 7. F]New construction
2.F71 am a sole proprietor or partnership and have no employees working for me wi $. C1 Remodeling
any capacity.[No workers'comp.insurance required.]
.
3.7 I nm a homeowner doing all work myself[No workers'comp.insurance required.] 9. Q Demolition
'
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.P-J Electrical repairs or additions
proprietors with no employees.
12.n Plumbing repairs or additions
5.❑1 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.insurar+ce.t
6.�2 We area corporation and its officers have exercised then right of exemption per MGL c. 14.n 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 subcontractors and state whether or not those entities have
employees. If the sub-contmctorz have employees,they must provide their workers'comp.policy number.
lam an employer that is providing workers'conipeitsadnrr 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 certi Irnder die pa' and penalties of perjury that the information providedrove is true and correct
SiQrtatur :
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
Massachusetts
J •, F`� -G
DEPAR=NT OF BDILDING INSPECTIONS
x
ra
212 Main Street • Municipal Building yVj;•,, C4
Northampton, MA 01060 ssiyy grj1��
l
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, •.(insert full legal name), born (insert
month,day,year),hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or
work on a parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'
exemption, does not involve the field erection of manufactured,buildings constructed in accordance with
780 CMR 110.83.
3. I qualifij under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one-or two-family dwelling, attached or detached structures
accessory to such use and/or farm structures. A person who constructs more than one home in
a two-year period shall not be considered a home owner.
4. 1 do not hold a valid Massachusetts construction supervision license and, except to the extent that I
qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of
the project or work on my parcel, I am not engaged in construction supervision in connection with any
project or work involving construction, reconstruction, alteration, repair, removal or demolition
involving any activity regulated by any provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or work on
my parcel,I acknowledge that I am required to and will act as the supervisor far said project or work.
Signed under the pains and penalties of perjury on this day of 20_.
(Signature)
i
i