20-006 x
BP- 2011 -0338
GIs #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP- 2011 -0338
Project # JS- 2011- 000554
Est. Cost: $18738.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GOUGEON & LOCKE 001992
Lot Size(sq. ft.): Owner: ZAWALICK AMELIA K & E HUGHES C/O ELIZABETH HUGHES
Zoning: RR/WP/WSPII Applicant: GOUGEON & LOCKE
AT. 508 SYLVESTER RD
Applicant Address: Phone: Insurance:
26 South Street (413) 268 -9323 Workers
Compensation
WILLIAMSBURGMA01096 -9726 ISSUED ON. 1011312010 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT SIDING & WINDOWS
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.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 10/13/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
[parttnent tk qty
City of Northampton Statas rPermlt F
3 � 2 Main Street ��+errrtit 1
Buiiding Department Cft/1�Cutip
,J
Room 100 1tferettbility
Northampton, MA 01060 Tvun Sets ofStfutrttirai Plans
phone 413 - 587 -1240 Fax 413 - 587- 1272itlS�te�ne
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address This section to be completed by office
Aladler IV Map Lot ' Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Gfi G�Y /e.S /li� / es 5�� � /rtS ftv' kl I e"i;
Name (Print) Current Mailing Address: " � A
v
Telephone
Signature
2.2 Authorized Agent:
J'*19F L-W*1�, Z6 SL
Name (Print) / Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building �r , p (a) Building Permit Fee
2. Electrical o (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) f 7 ��C? Check Number
This Section For Official Use Onl
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
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
Frontage
Setbacks Front
Side L: R: L: _ R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg & paved
p arking)
# of Parking Spaces
Fill: ._
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW YES
IF YES, date issued:'.
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page and /or Document #'
B. Does the site contain a brook, body of water or wetlands? NO DONT 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 there any proposed changes to or additions of signs intended for the property ? YES NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 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 ❑ Addition ❑ Replacement Wirpdaws Alterations) Roofing
Or Doors E
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [bl [0]
Brief Descr,j.,pPtion of Proposed
Work: L4If/Vi��S7lS
Alteration of existing bedroom Yes _L,— No Adding new bedroom Yes L - -- No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet NZIL
6a 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
1, " /`lT� I "UCH 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.
6X2IZC6 &4
Signature of Owner Date
as Owne uthorized
Agent h eby declare that the statements and information on the foregoing application are true and accurate, to the best of my know a pr'
ief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Own Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su pervisor : Not Applicable 0
Name of License Holder �G'`" r7 �' ' I7 ! 2—
License Number
Address Expiration Date
Signature U Telephone
9. Registered Home Imorovement Contractor: Not Applicable ❑
Company Name d ^ T Registration Number
1
GWN & LOCKF y.
Address Expiration Date
1�L1 MA nz__ Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 26C(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....... ❑ No...... ❑
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