30A-046 (7) t `
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancv
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
jermits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
l; understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
t - ' •
r $ - r
- 4 .
The Commonwealth of Massachusetts
Department of Indus Accidents
Office of Investigations .
600 Washington Street
--- lif ---- a Boston, MA 02111
_.,
• ' www.mass.gov/dia .
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individn21): „. 554:7,i,-/-4., fipki. 4
• Address: 7 x /7J ,. .
, i
City/State/Zip: .Pc=e4.--frc (a - -44-1 Phone.#: (;C.f 2je)3
. -
Are you an employer? Check the appropriate box: • Type of project (required): " ,i
1.0 I am a employer with 4. fl I am a general contractor and I
6. 0 New construction
have hired the sub-con.tractors
.employees (full ancVor part-time).*
. I am have no a sole proprietor or partner-
," ' cl enailoyees
Sup an listed on the attached sheet
These sub-contractors have. 7. 0 Remodelin3
.8. ID Demolition
employees and have worke rs'
working for me m any capacity. 9. El Building addition
[No workers' con insurance _ coi:op_insuranceA: _ •
10.0 Electrical repairs or additions
required] • . 5. 0 We are a corpoi-ation and its
3. 0 I am a homeowner doing all work officers havetcercised their . 11.0 Pluming repairs or additions
/ b
myself [No workers' comp. right of exemption per MGL 12of repairs .
insurance required.] t c. 152, §1(4), and we have no
13.0 Other
employees. [No workers'
comp. insurance required] • •
Any applicant -that checks box #1 must also fill out the section below showing their workers' compensation policy infonnation. - - .
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 mar of the sub-contractors and state whether or not those entities have
employees. lithe sub-contractorshave employees, they must provide their workers comp. policy number.
I am an employer that is providing workers' compensation 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 requited tiricter Sectiiiir 25A c. 152 can lead to the iirOsition of Min:tine penalties of a
fine up to 51,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised That a copy of this statement may be forwarded to the Office of
IiiireitigatiOns - cif the for iiiiiiiince COverageVerificatiori. ------ _ - :=: - .7.7, --- .
/to hereb_ycerti& under' the pains.and penaldes ofperjury that the information provided a.bo ve zsirue wzdcorr 1
Signature: , ---e
A a-- Date : d P /1/1/ c ) • • ,
. ,
Phone it: :C6:1 ------- 2- 3 63 -
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 , i- . .
Contact Person: Phone #:
s �
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : $ / �I f,') 4 `► t(e) 2 0
License Num r
7 gr` 1 pee 4,, 23 /
Address Expiratiio ate
°Z� i ,�✓ G CS 2 3 o
Signature Telephone
9;: ietii&te i litc lr bro erdeint o lctor 3 &: f` gi tz a Not Applicable ❑
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.
Signed Affidavit Attached Yes ❑ No ❑
I .. &: m a wnerk: mttion
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
� . N.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition 0 Replacement Windows Alteration(s) El Roofing AIL Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [0]
Brief Description of Proposed�i� 4 - k _ ' - SC ?mot 4----".)q-"` ,+C.
Work: X- 'T�'� � e � it WO t -044 1gr pro 6
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa aiNi r fititisi anct a i i a 66th itiiki ii'sn g rdiii itili ifiso i iv It :
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
I, b ob r(J.. ‘ie t - t z_ , as Owner of the subject
property j� 1 _ /
hereby authorize :..?'i�"C� 1 t sA ` (
to act on my behalf, in all matters relative to work authorized by this building pe it application.
Signature of Owner Date
et (1_ ,`1.± Z , 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.
Signed under the pains and penalties of perjury.
Print Name ; -�
(D ,L k I ) /0
Signature of Owner /Agent ate
if N
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 m by
Building Department
Lot Size i _ _
Frontage 1 1i t
Setbacks Front
Side L: R:1 L:= i R:`
Rear 1 1 i y
Building Height ; i 1
1
Bldg. Square Footage i 1 1% 1-1 I I 1
Open Space Footage
(Lot area minus bldg &paved } I I
parking)
# of Parking Spaces
Fill. ,. _ r .. _ ,_....._ , , ,..m_ _ _ __a _ „_,
# €
(volume & Location) is i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW ED YES 0
IF YES, date issued:1 I
1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW fe YES 0
IF YES: enter Book 1 1 Pagel i and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES e
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES ® NO A
IF YES, describe size, type and location: € `
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0
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 0 NO e
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
s �
City of Northampton
Building Department e ' , °�
212 Main Street r
Room 100 ,
. a
l ; � 1 ` ::10 Northampton, MA 01060 % '
J phone 413- 587 -1240 Fax 413- 587 -1272
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 Address:
3 7 ` Map L'ot Jnit
Zone Overlay District
11014
Elm St District CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
- 1 7 Z
Name (Print) Current Mailing Address: V
��. 4glf -o z2
tt�.�� Telephone
Signature
2.2 Authorized Agent: R � /�� � ���
Sk P/004 /9/ -/ -t, / v' ez Name (Print) Current Mailing dress:
fr- 2-7
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by perm it applicant
1. Building ��, a ` (a) Building Permit Fee
2. Electrical a (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection ' 's
6. Total = (1 + 2 + 3 + 4 + 5) 2 75" Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0188
APPLICANT /CONTACT PERSON STEVEN PISTRICH
ADDRESS/PHONE 7 RIVER RD SOUTH DEERFIELD (413) 665 -2303
PROPERTY LOCATION 37 LEXINGTON AVE
MAP 30A PARCEL 046 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 3.6M Fee Paid
TYpeof Construction: REPAIR TREE DAMAGED GARAGE & REROOF
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 048770
3 sets of Plans / Plot Plan
THE FOLLO ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ION PRESENTED:
pproved 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
ature of guild' g Officia 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.
37 LEXINGTON AVE x'. BP- 2011 -0188
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30A - 046 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-2011-0188
Project # JS- 2011- 000319
Est. Cost: $2975.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEVEN PISTRICH 048770
Lot Size(sq. ft.): 15812.28 Owner: SOUTHERLAND MICHAEL & DEBRA HERTZ
Zoning: URB(100)/ Applicant: STEVEN PISTRICH
AT: 37 LEXINGTON AVE
Applicant Address: Phone: Insurance:
7 RIVER RD (413) 665 -2303
SOUTH DEERFIELDMA01373ISSUED ON:9/2/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR TREE DAMAGED GARAGE & REROOF
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 9/2/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
( i > .'- i
1 l F +13
r
r _________
\r
O z- Q
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y
i I a w„ o^/ , l ei' '7 14 ' cc....-
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0 Q \ \ °.`
d-aiS/ 0 0
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1 14 r f1 -
--,flk,/ L C1-, L Z'
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealej insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occunancv
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
iiermits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
,,
f
The Commonwealth of Massachusetts
Department of Industrial Accidents
* —
Alk " a
Office of Investigations
* ...– 1—. ,......
600 Washington Street
Boston, MA 02111
www.mass.govidia
•
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization./IndivichinD: ,_)f i.-t 4-7 f /14 2 4
Address: "7 A 1 t I/ e 4.-- R. cl ... •
,
City/State/Zip: V c lci- ilvt Phone.#: 6‘ .5 2 .;',--,
,"
Are you an employer? Check the appropriate box: Type of project (required): /
1. I am a employer with 4. 0 I am a general contractor and I
El
employees (full and/or part-time).* have hired the sub-contractors 6. New construction
fisted on the attached sheet. 7. )5...Remodeling
2. 5g.I.am a sole proprietor or partner-
These sub-contractors have
ship and have no 2.loyees t .8. 0 Dernolidon
working for me m any capacity ertAgoyeesand have workers 9. 0 Building addition
_ comp.insiTmner.
[Na workers' comp. insurance #:
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. 0 I am a homeowner doing all work officers bave4xercisecl their .
. -,- 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 0 RD I -
12. o repaus
insurance required.] t • c. 152, §1(4), and we have no
eavloyees. [No workers' 13.0 Other
comp - =mace required.] .
*Any applicant that checks box #1 must also fill out the section below showing their-workers' compensation policy information.
t Homeownera who submit this affidavit indicating they are doing all work and then hire outside =tractors mast submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employee; they must provide their workers' comp policy number.
/ gm an employer that is providing workers' compensation 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 pulicy number and expiration date).
Failure to secure coverage as required under Section 25A CfMGL c. 152 can lead to the Mposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK-ORDER and a fine
of up to 5250.00 a day against the violator. Be advised 'that a copy adds statement may be forwarded to the Office of
Iiiiiitikitions Of the DIA for insurance coverage veriffeitinri . . - ----- --- , - , __
/ ilo hereby certifi under the pains and penalties ofperjury that the information providettabove_isirue_and_corrpct
Signature: ,tirt--7 A vie 1 . ri f-e, 4-0 2-‘ (0
. 1 .0t .
. _
Phone it: • 23 ay - -
• Official use only. Do not write in this area, to be completed by city or townfficiaL
City or Town: • Permit/I.Icense #
Issuing Authority (circle one):
.1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector
6. Other .
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: / Not Applicable ❑
Name of License Holder : j 7'C�G� / ( 1 315
License Number
7 RI yr - liee,, `r(J . X72 -3// 2.
Address Expiration Date
d;21_. X65 7 30 '3 Signature / Telephone
9..Rectistet' d HcHme=litiritveiter Ufi efaiiV malls i 5 .. - = t Not Applicable ❑
/ l 2 389
Company Name \ Registration Number
,C Address Expirafon 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.
Signed Affidavit Attached Yes ❑ No ❑
1 :: .ome O ttil E; en h4 n
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 1083.5.1.
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 -vear 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
,
SECTION 5- DESCRIPTION! OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) j2t Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [El Siding [O] Other [E]
Brief Description of Proposed / /� / / / Pity,- Work: Dt:�►viSi, X/ heh ciao,- a ,d /'f ebu, le Ili el �f.Q� c fCW PiQ?rr 141c 4.- 15( 15-j
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet NCIE c' .L7` /s vac /ra+•- wilcat is i eeJc4 ~t'1/ S&.— /he d e fli 0
sa fib ro -a r ° +a' rah tu exi i a s t ° c 0 In o eWil O t m:
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
I, P 1. l" , ok. Z , as Owner of the subject
property c- p � P � ,
• hereby authorize . 3 —O t y \ C r 1 S ► s n ` Cts
to act on my behalf, in all matters relative to work authorized by this buil ng permit application.
ct. 9 110
Signature of Owner Date
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
I j tte4" l f" c / c 4 , 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.
Signed under the pains and penalties of perjury.
5 e/Y 0 ? 17
Print Name
t
Signature of n er /Agent Date
t
q
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 ? -- _ 1
Frontage i • t I 1
Setbacks Front l j L J i
Side L:' _ ` R: L:l R: a
Rear ' I
l
Building Height r i ��"� 1 t
Bldg. Square Footage ( t % f 1 3
a
Open Space Footage %
(Lot area minus bldg &paved 1 0 � :_ .?
parking)
# of Parking Spaces --
Fill: I
. (volume & Location) a a
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book ; Page € and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO (- DONT KNOW Q YES i
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ,Date Issued:
C. Do any signs exist on the property? YES 0 NO GI
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO t`
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 0 NO 9D
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
I
City of Northampton
Building Department
212 Main Street
3 ZQ Room 100 .E E
rthampton, MA 01060 - �� °�
phosie 41 587 -1240 Fax 413- 587- 1272
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
e 7 Map Lot Unit
Zone . OvertayDistrict
Etm St. Di CB District
SECTION 2 - PROPERTY OWNERSH1P /AUTHORIZED AGENT
2.1 Owner of Record: 0/02.
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Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: nn
Name (Print) Current Mailing Address:
Kai 23o
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
2. Electrical _ (b) Estimated Total Cost of
5 U .0 Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Ts eo Check Number `ot � �7
This Section For Official Use Only
Date
Building Permit Number:_ Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0272 pA)
p ca,v.
APPLICANT /CONTACT PERSON STEVEN PISTRICH
ADDRESS/PHONE 7 RIVER RD SOUTH DEERFIELD (413) 665 -2303
PROPERTY LOCATION 37 LEXINGTON AVE
MAP 30A PARCEL 046 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ,
Fee Paid &O(o2 0 J
Tvpeof Construction: REMODEL KITCHEN, DEMO & REBUILD KITCHEN FLR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 048770
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
ey. • •el.
9 /
re of Building a 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.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
37 LEXINGTON AVE BP-2011-0272
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30A - 046 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 -0272
Project # JS- 2011- 000452
Est. Cost: $7800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEVEN PISTRICH 048770
Lot Size(sq. ft.): 15812.28 Owner: SOUTHERLAND MICHAEL & DEBRA HERTZ
Zoning: URB(100)/ Applicant: STEVEN PISTRICH
AT: 37 LEXINGTON AVE
Applicant Address: Phone: Insurance:
7 RIVER RD (413) 665 -2303
SOUTH DEERFIELDMA01373ISSUED ON:9/28/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL KITCHEN, DEMO & REBUILD
KITCHEN FLR
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 9/28/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner