18D-053 (3) 80 DAMON RD-#2205 BP-2001-0743
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18D-053 CITY OF NORTHAMPTON
Lot:-043
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0743
Project# JS-2001-1399
Est.Cost:$2400.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: STEPHEN SMITH 068354
Lot Size(sq.ft.): Owner: MOCK WILLIAM&CHRIS i OPHER ALDRICH
Zoning: GI/WP Applicant: STEPHEN SMITH
AT: 80 DAMON RD - #2205
Applicant Address: Phone: Insurance:
182 MAIN RD (413) 863-9195
GILLMA01 376 ISSUED ON:3/22/01 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL BATHROOM & KITCHEN CABINETS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Final' C°/ " Final: ///`d
G / �� Rough Frame:
Gas Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:D/f 7.Q. 1,)
THIS PERMIT MAY BE REVOKED BY THE CITY F NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
‘ ?"°°9-41"4(5tc"Certificate of Occupancy � w/��� Signature:
1 Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 3/22/01 0:00:00 6877 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony P-,tillo
File#BP-2001-0743
APPLICANT/CONTACT PERSON STEPHEN SMITH
ADDRESS/PHONE 182 MAIN RD (413)863-9195
PROPERTY LOCATION 80 DAMON RD-#2205
MAP 18D PARCEL 053 ZONE GI/WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 1L297 _
7 lR`
Typeof Construction: REMODELBATHROOM&KITCHEN CABINETS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 068354
3 sets of Plans/Plot Plan
THE t_OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
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
-3 "o�a2 'Ol
Signature e of Buildi fficial 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.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit _ _
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans_ _
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property/n Address:
So UfinO J 2 2 J Map Lot 63 Unit C/ 573
/�/
„ Rt/J nm?Mk)t i Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
iD;//I ftm ACk 7 e�05m F,e /A /W .th uct c/1✓a��h inxT,ci
^" me(Print) Current M ng Addres
2'; Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature 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
16 ()) •oo
2. Electrical , e70 (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) ad , fi L) Check Number 127 f
�1This Section For Official Use Only
Ruilding Permit Number: t-'O - t3 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever een issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, bodyof water or wetlands? NO DON'T KNOW
YES
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 theer any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
CTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
`Brief Description of Proposed Work: aa[ fiichis CQc�1i-� r--
Alteration of existing bedroom Yes /No Adding new bedroom Yes L., No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
a. Use of building : One Family ✓ Two Family Other
b. Number of rooms in each family unit: .S Number of Bathrooms
c. Is there a garage attached? /tiC--)
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves wv Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
Type of construction wdxsxX
i. Is construction within 100 ft. of wetlands? Yes L 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? 17 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, "12/L/ filet4 as Owner of the subject property
hereby authorize ' '7 L1Z S/Y/ / -"h to act on
my behalf, in I matters r ativ to work authorized by this building permit application.
1
21
Signature of Owner Date
I, Gv/L1//¢n'9 .2 Mec , 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.
^';ned under the pains and penalties of perjury.
z.v i zzin in
Print Name //
/"'vim � (/ 7/
Signature o Owner/Agent Date
SECTION 8 - CONSTRUCTION SERVICES
Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 5 `ec (151(4 I. �►-i O o 35
License Number
t/friCkt Rd c-c �t d t 96 // / - 2 oO;L
Address . Expiration Date
.PcjiP4 7 Vi3-g 3 ?/SS�
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable 0
Company Name Registration Number
Address Expiration Date
Telephone
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.
c'-ned Affidavit Attached Yes 0 No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own 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 homeowner.
Such"homeowner" shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
•
v:C"AM PT•
a tEaf Northampton
•
giassarllnartta
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
37- )Z ►-_ ? 3 •
cent tees
(� i )
with a principal place of business/residence at:
•
f'(Z.-� mac€ Zr ((Q2 (� c// b 7 - e3/?>6 (phone#) 4ff3 - G�- fS-
(street/city/state/zip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
:1 ( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
•
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet if necessary y to include information pertaining to all contractors)
(1'rl'am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who employ persons to do uTaint.n'or.- construction or repair work on a dwelling of
not more than three units in which the homeowner resides or co the grounds appurtenant thereto arc not generally comidcred to be
employers under the worker's compensation Act(GL152,sa 1(5)),application by a homeowner for a liege or permit may evidence the
legal status of an employer under the Worker's Compensation Act
I understand that a copy of this statement may be forwarded to the Department of Industrial Accidents'Offioe of Inwrsnoa for the
coverage verification aid that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
oomisting of a fine of up to S1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
the of S 100.00 a day against tnc.
) For dgmtmertal use only
Permit Number
"7/
\i"V'r _ • Map# --Lot#
Si of Licensee/Permittee Date