38A-074 (5) 155 GROVE ST BP-2021-1175
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:38A-074 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2021-1175
Project# JS-2021-001972
Est.Cost: $15 100.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 16335.00 Owner: CANNON APRIL
Zoning: URB(100)/ Applicant: CANNON APRIL
AT: 155 GROVE ST
Applicant Address: Phone: Insurance:
155 GROVE ST (413) 537-9760 ()
N O RTHAM PTO N MA01060 ISSUED ON:4/16/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:CONVERT GARAGE TO LIVING SPACE
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.
to if 2 Tit •
Certificate of Occupancy Signature: /
FeeType: Date Paid: Amount:
Building 4/16/2021 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
`RECEIVE
APR 1 3 2021
The Commonwealth of Massachus tts FO
1-7
Board of Building Regulations and St da�rpdg „ FOCI ILITY
/ Massachusetts State Building Code 78 CIv1WT OF BUILDING INSP F.° - NORTHAMPTON.MA 01060 USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 6n''o?/.... /f 7 6 Date Applied:
ie.../i/J 70::)5 ,____,. q- /6-2614
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Propert Address: 1.2 Assessors Map& Parcel Numbers
is 5- Ciro jc. StreCA- 164 91
a Is this an accepted street?yes ,/ no Map> mber� 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 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
A pri I. �yy K.o►'s _ No r' o�►,,p+v AAA., 0(606 O
Name(Print) City, State,ZIP
I5S &vov, 54-, l 13 -c3-2- 9766 art')icAbiA..4l443'
No.and Street Telephone Email Address /h s„,cow
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building I;i( Owner-Occupied . Repairs(s) 0 Alteration(s))til Addition 0
Demolition 0 Accessory Bldg.0 Number of Units 1 Other 0 Specify:
Brief Description of Proposed Work'-:___ C,phv rtq 1 C6f q 4r%i '0 (;V- ,SPtC
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ -7' OO O I. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ u
1/ DOG 0 Total Project Cast'(Item 6)x multiplier x _
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ 4 060 List•
:_
/ \
5. Mechanical (Fire
Suppression) $ /D o Total All Fe .-_f ' Ao
Check No e Check A ount: L) Cas' Amount:
6.Total Project Cost: $ l 5,boo 0 Paid in Full 0 Out ni .' •i. . ce Due:
SI6 egg
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: 3$a LOT: 3 8 4 -O 7 Lj
LOT SIZE:'% f 4, 3 34„ 3 'a,r fL
REAR LOT DIMENSION: I I D , 13 6 1
REAR YARD
SIDE YARD 15 SIDE YARD 3 3
1 f
t/luln CJYft >�.
FRONT SETBACK 3 d f
FRONTAGE I 6 6 r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIPR Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6: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 0 No 0
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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
A O‘ COPW%Ov- _ `f -12 - 2 I
Print Owner's or Authorized Agent's Name(Electr nic.'ignature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(FIIC)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.govioca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (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"may be substituted for"Total Project Cost"
City of Northampton
� SAS it;
> Massachusetts
e:
DEPARTMENT OF BUILDING INSPECTIONS•
212 Main Street • Municipal Building may_ mob.
Northampton, MA 01060 Jsy ��`�'','-
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, 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:
Location of Facility: vJL C ((
The debris will be transported by:
Name of Hauler: A ? c \ (�'1 V�d
Signature of Applicant: Date: y 'ti-2c t
„.....„.........„„„.„...._ The Conimontrealth of..klassocifirsetts
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4.1.,.,...c.3.. Department of Industria1.4ecidents
1 Congress Street,Suite 100
Boston,114 02114-201'
Iritlr.ittass.govidia
Vi.,cker-,* Compensation Insurance Affidalit:Builders'Contractor: Electrician:Plumber:.
TO BE FILED WITH THE FERNITrTENG AUTHORITY
..-kpphcant Information Plea:*Print Legibly
Nairn.(Tiusmess..Orgai-nnon.Indnaduals,..
Adcire ..
City!StateZp: FlicAle .--1-.
. _....... ... ......._„,
Are yea as essplay.ar*C heck the approptra op bax. ..., T7,pe of project(r.equirtAt:
...0 I am a anaplayar akith etriaF la:eaat,lira.and c•pa--t-fasaJ' 1 ; Lill..,`:eW commiction
0.:=a aclo proprinrcl:c:pn•caa•-;.i..ip zad lava no anzplariva:wonizina far=a Lt. L- 8 atianociehn?
lary:apact-72. [Nc rexikerl'ccinp thiu--ancs roq-.:arsd.1
El Demolition
3,13 I ant a lacirdacranar damp all or tnr.iilf.Ma ravarkaaa.tan* anattansa Pic:acad.'.' .: •
1 tO 9 alfiCana ad,dition
491 i=z hcamtvwnaz a=d will I:4 barn*caniraciara ao ccaninct all aro*031 My F cpury I tri:2
4 Z1113,that 32 C OZMIC7C TS iMthre itat 0 UN:4w;conspana*.la iaralthCi cr too:al* I 11.0 Electrical i epars or adilill1011.”,
proptiatwa wz=nc amplcytar.
12 El P:I/EllbITIE repair.or addition:,
Di a=a!austral contra:lac and:/aa=rod this istb-ccz:zacron,lroad ca dos ana,:nod 1:144;
ontrrona , 10fe :Thabcazr havea ad trA = 14.Ej Other-
ts 0 Ws are a ccaperrataa and its officaca-lava anz:ciaad;hair ritaid cf exemption par MGL c
'=.1 and w a Sr.a a.,•.,am;:zysa:,r.,,la werlian'camp.lanuranca raga:mil
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*Air;apc lac=tizat cna-;:.;k,:ya a:=i.:..t;al;,:,fit crat tlia;act.=law alrang ta.ir nec•ka.-....cat pahry nalonnatian
'Masao-wrier:74'bii mt=r,..-,..,af5dt ac at:4 6ay 3.11,dc Las a wark aad than b.zo o7...r.;da;natractcr.salt t.:•aza.v.!a Z411 affida,::::indicant Inch
IC cztricmst et.1.1:bari zh;..:bci analt ar:a.:':aid.an addiLana:.la ::B.,7-a-inf-.1.1c,an=of:la v.:::-ccttrac:ar:r„sui.„ .:s waatizar cr 11.31 frao to antos`area
ar.;a1c7..soa if daa;.11.‘a-:cattrac;tIT 1 hr:4 arac'ia.y4141.tna,zr...tilt::ar:T: thee '%.'cicn:-. ca::_..:, pc li,..:".-=mbar
I am an employer that is providing workers'COPtipell canon rn in;°nee for my emplosves. Below is the_polio-and job site
informalioit
Inurarce Con:parry Name:
Policy g or Self-ins.Lic gr. Evil-anon Date
Job Site Addre;: CStateZip:
Attach a copy of the worktrf compensation policy declaration page(showing the policy number and erpiranon date).
Fure to secure ccr;erage a:.required under MCiL-.-_.., 152,74.15A i..;a ritasin-il...iolation ptminhable by a five up to 51.5C..0.00
and or one-year ninpnsoninent.a;well al-.civil penalties in the form of a STOP WORK ORD .and a fine of up to S250 00 a
day af..rai=t the vtolatot A copy of thr, 7,tatent may be forovaded to the Office of lzr.-e...,tieationi of the DIA for insuranc.e
- .' ---7'.."•erificatici:
I do her eirs cerrifi.undo Ilse pains and penalties of peijuri that the information provided above is true and correct
Signalize:
af-4,:ti Cei,,A.4 i.-e-)---- Date. —/2 —.2._o 2/
Photlo . yig -5-3-7 - 611,6 0
Official use only. Do not write in this area,to be completed by-city oi roan official
City or Tonal: Permit LicetrA.
Issuing.kuthorir,, (circle one):
1.,Board of Health :,Building Department 3,C it- Town Clerk 4,Electrical Inspector 5, Plumbing Itcpector 1
6,Other
Contact Penn: Phone g;
City of Northampton
t == 5
Massachusetts ?g
A r. < .
0.4
DEPARTMENT OF BUILDING INSPECTIONS SAa !
212 Main Street • Municipal Building
Northampton, MA 01060 �0
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
ri I (4/i/i v (insert full legal name), born —8
7v(insert
month, day,year), he e 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.R3.
3. 1 qualify 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 for said project or work.
Signed under the pains and penalties of perjury on this t2 day of 4e' ( ,202/.
(Signa re
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