32C-318 (10) File #BP-2021-2264 CAi Ls.,:, 0-,/)319-1
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APPLICANT/CONTACT PERSON:BENSONOFF DANIEL & KOKORO / • '
47 HENRY ST NORTHAMPTON, MA 01060
PROPERTY LOCATION 47 HENRY ST
MAP:LOT 32C-318-001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Building Permit Filled out
Fee Paid $65.00
Type of Construction: YURT, PLATFORM WITH REAR DECK AND STEPS ( 1D T C, ..i
New Construction -J
Non Structural RenovationsI-9
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License �.
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 PERM R/LIVEQUIRED UNDER:§ J)' j F�2-6 Cf41 - '_t_.
Intermediate Project: Site Plan AND/OR Special Perm it 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 Ava ila bility
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
$04L, 44,. ,.
it, la/Jo/at
Siglature of Building Official I a 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.
The Commonwealth of Mass chus tts `.r LI i 1
;( r Board of Building Regulations a d S no. o FOR
1 Massachusetts State Building C e, 7 0 his' — 6 CIPALITY
202� USE
Building Permit Application To Construct,Re air, e Or Demolish a R ised Mar 2011
One-or Two-Family D • n,0°T nukom;r ;
This Section For Official Use Only '---. o,0, 0�
�_...
Building Permit Number: 60- 31- 3 -
' Cl c4 Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Prope ty Address: 1.2 Assessors Map&Parcel Numbers
Li 7 1Cn ri s4-- 3,a
1.1 a Is this an accepted street?yes no aM p 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 0 Private 0 Zone: — Outside Zone? Municipal 0 On site disposal system 0
Check iff yes!:
SECTION 2: PROPERTY OWNERSHIP`
2.1 Owner'of Record:
-Da'; c1 _ 13e„cono PC hl or N+(-1-,e 6 -, I hit A 0 1 o eo
1
Name(Print) City,State,ZIP
/ ? /ferry Sf __,_ 76 7/lcI2.l )CeAcono ®11,,,,il. corr,
No. and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2 (check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. l / Number of Units Other 0 Specify:
Brief Description of Proposed Work':_ Q ,,,,, et cc a 5i a ry o,.,; V 1 a S' ��ii•.,,.,e'-f.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item l;stnnato:d Costs Official Use Only
(Labor and Materials)
1. Building g 1. Building Permit Fee: $ Indicate how fee is determined:
--- 0 Standard City/Town Application Fee
2.Electrical $ 0 Total Project Cost;(Item 6)x multiplier x
3. Plumbing $ —I 2. Other I;es: $
4.Mechanical (HVAC) $ --.— —� List: —
5.Mechanical (Fire — -- —
Suppression) $ Total Al]F'ee _ ) /,y/�
i Check io.�V_Check Amount: l!i I
6.Total Project Cost: , 5 , ❑Paid in Full^ 0 Outstanding Balance Due:
The Commonwealth of Massachusetts
1-_ 1-::-...„-: (0,
\-- ilitiztar
Department of industrial Accidents
1 Congress Street,Suite 100
Boston, MA 02114-2017
www.rnass.gov/dia
,,,,..;:,..,...,
14 pikers ('ompensation Insurance Affidavit:BuildersiContructors/ElectriciansfPlumbers.
'II)BE PILED WITH IIIE PERMITTING AUTHORITY.
Applicant Information Please Print Et2iblv
Name i Bus inzsslOtgantratiOn,EMIL\idua i l. Gv1V1.‘ CIt.mSono C-4--
Address:
City'State/Zip:,LV,Aryk.sym p r!.),N tiVA- 0 10 4 t Phone #: 3‘o -"2 i‘
Ale rail an clinpieryte!Check the appropriate box: Type of project(required):
I.E3 I am a erapkiyer with________ employees(fa aukor pritt-timet• 7. 0 hew construction
2.71 I ant a sok proprietor oi partnership and have no employees worittns tor me ut g. fp R.moddifig
— capacity.[No workers'comp.insurance required.)
9. 0 Demolition
titling:10441W!i101118 lit Vi.1.141 Itly/eff.[No woLises'corm.trourance room-esti"
4tif
100 Building addition
4
..;',int 3)atrliaatitilef and will be fumy contractors to condors ail work on sty pix.rporty I will
- rntsore that:LII contractors either have V.01kterN'LIwrip4.-rmation inseranw or are sole ILO Eke trir cal repairs or additions
pt aprwtoli with no ihnployees.
12.0 Plumbing repairs or additions
Ogi unt:actor and I have hired the sidoccintrneures hated on the attached sheet
e
!ICI Roof repairs
' TheLe set,Lairratrictorti haw employees and hav workers'comp.insurance."'
I4.-ca6ther Acc..„5,.,
6.0 We ste a corparation and its officers have*Itemised their NO of exemption pci NMI c.
1 ..1 $1141..and we have MI etVillIcel'ii.INo workers'comp insurance required.]
'Any appl;CV4i that litt0:34 boa t,i most alma fill out the section below shovi ins their WarkLeS;compensatiun policy informatteo.
' Honscownicis who sohnitt this affuh.vit thit2Catlf1M they AM doing all work and&en hoc outside co/via:mut',must alikwitit a isev,affulieN it:ixiicalius mbch,
;Contractors that check this ho mutt attached en*Winonai sheet show ing the name or"the subs-Lauractors and atatC 11/41u..iher or not those entities haw
Lit.101.1.10.."3. It the ioh-contractoss hoe env hryers.they mum provide their workers'cosneLtiliCy Mitathtl.
< ^ ...,...—
I am for employer that is providing workers*compensation insurance for my employees. Below is the polley and job,,,fie
information.
Insurarwe Company Name: _
Policy#or Self-uts.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 pine up to S1,500.00
arid or one-year trapriqonment,as well as civil penalties in the tomi 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 Invitigatiorts of the DIA for insurance
co..,er age Verification.
,/do hereby certify et der the pains and penalties of perjury that the information provided above is true and correct
Official use only. Do not write in thin area,to be completed by city or town official
City or Town: i'ermixtLirense#
issuing Authority(circle one): --- - — ' —
I. Hoard of Ilealth 2. Buihling Department 3.CkytTown Clerk 4. Electrical Inspector N. Plumbing Inspector
(a.Other
Cori tact Person: Phone*:
-----
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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 1 ype Description
U Unrestricted(Buildings up to 35.000 cu. It.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I 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 . ❑
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.
OV• --�nS o n a I 2 Z Z
Pri wner's or Authorized Agent's Name(Electronic Signature) / Dati
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(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.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,fmished 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
Massachusetts ��as ,sci
i F.! �G
DEPARTMENT OF BUILDING INSPECTIONS pn
212 Main Street • Municipal Building 0%
Northampton, MA 01060
4
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: 1l Akttr ICY c_It m3
Location of Facility: 2 3�� ��s�-��M(o �� rJ ,
The debris will be transported by:
Name of Hauler: AI S Prz_ r - Ko1oSZYc.
Signature of Applicant: Date: JIli a Z al
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE: 0 9 0.c r es
REAR LOT DIMENSION: 3 0 0 X /0
REAR YARD / r
j In
1 (
r ,
SIDE YARD `) SIDE YARD
FRONT SETBACK
FRONTAGE 9
City of Northampton
�q,1''AA�fiI W»•
Massachusetts tie . ,. fy
l ,G
DEPARTMENT OF BUILDING INSPECTIONS ?�
212 Main Street • Municipal Building. Pt,
Northampton, MA 01060
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
iVil8e
I, cn irl i e\ ' -Rn S ono -1-- .(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 ti9 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. I 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. I 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 2 2 day of ° 6� , 20 Z[.
(Signature)