36-201 (6) 39 WINTERBERRY LN BP-2016-1119
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-201 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-2016-1119
Project# JS-2016-001910
Est. Cost: $10500.00
Fee: $133.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY STOKES 083602
Lot Size(sq. ft.): 92347.20 Owner: WILINSKY JOHN F
zonine: Applicant: TIMOTHY STOKES
AT. 39 WINTERBERRY LN
Applicant Address: Phone: Insurance:
20 TURKEY HILL RD (413) 695-2264-0
WESTHAMPTONMAO 1027 ISSUED ON:3/22/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.REMODEL BATHROOM
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 3/22/2016 0:00:00 $133.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of Permit:
---- ,- Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/SepticAvailability
Room 100 Water/Well Availability
MAR 2 ( 2016 Northampton, MA 01060 Two Sets of Structural Plans
phanei13-587-1240 Fax 413-587-1272 Plot/Site Plans
DEPT C S Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Pro ert Address: This section to be completed by office
� Map Lot Unit
/ Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
I;' of "' W L,> ���` �.,
Name(P in Current Mallin Address:
uo_
Telephone
Signature
2.2 Authorized Agent:
Name(Print) �.. Current Mailing Address:
-
-z-
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 60 U (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
G o U Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1 +2+ 3+4+ 5) Check Number
This Section For Official Use Only
Building Permit Number-_ Date
Date
oo (sued:
00
Signature: 3 !(,,�-� '
4,
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
"Chis column to be filled in bti'
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: 1.:, R:
Rear
Building Height
Bldg.Square Footage 1lr,
Open Space Footage
(Lot area minus bldg&paged
parking)
# of Parking Spaces
Fill:
(Volume&Loc<tion}
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T 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 O DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O Date Issued:
C. Do any signs exist on the property? YES 0 NO O
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 O
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? YE, O NO 0
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 17 Replacement Windows Rooting E-1
Or Doors r_1
Accessory Bldg. El Demolition D New Signs [0] Decks [M Siding �j Other[Q
Brief Description of Proposed
Work: kt, 0 T:-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes V No
Plans Attached Roll -Sheet
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, t O i k as Owner of the subject
property
hereby authorize
to act on y behalf, in all matters relative to work authorized by this budding permit application.
-�
2I ) I �
Signature of 03%re�' Date
11 as Owner/Authorized
Agent her9by 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
Signature oN)w_ne_r7—ge-`rt Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supe'rvisor: Not Applicable 0
Name of License Holder: t V-1
License Number
Addresa' Expiration Date
Sigria4t,re Telephone
9. Registered Home Improvement Contractor: Not Applicable 0
7-W 770
Address ExpirAtion Dote
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....... 0 No...... 0
11. - Home Owner Exemultion
The cunrntczcmphmnfor"homco"ncn^ nus extended u`inet udo noo(\) or w*(2)k/mi|iem
and to allow xuch homeowner men-age on indi`idxa| for hire who does no/possess ulicense,provided that the owner acts
as supervisor.CMR 780, Sixth i��ition Section 108-3.$.1.
Derinition of : Yomoo (s) vhoo"nopanz| "//oodvnwhichhu/shcoxiduoorin/cndowrusido.on *hich /bcm
is,or is intended to be,a one or Ioo family, dv elling.attached or detached structures accessory to Such use and/or tarrit
structures. .
Such"homeowner" shall Submit to the Building Official.on a form acceptable to the Building Official,
responsible for all such work performed under the buillging t)ermit.
As acting Construction Supervisor Iourpresence onthe job site viUherequired from time mbmc.during and upon
completion o(\hc nnrk for which this ponnd is issued.
Also hcadvised that vi|hreference tnChapter )52 (\Ynrkom' Compensation) and Chapter |53 (Liability o[Employers|n
ErnploNces for injuries not resulting in Death) ofthc Massachusetts General Laws Annotated,you may be liable[o,pmnon(x)
you hire mperform vorkfor you under this permit.
The undrmi�ncd^homoovn�/'ccn\DcsuodossumcsmyponsihiU(yforcompUonocv\\h|hcS1NcRu�|din�Code.Otynf
Northampton Ordinances.State and |,ocu}Zoning |-uosyxd State of'Massachusetts General Laws Annotated.
Homeowner Signature
� The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
4 ` I Congress Street Suite 100
Boston,MA 02114-2017
www.niass.gov/dict
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le:4ibly
....
Name (Business/(hganizatiort/Individual):_-_ t —
Address: Z-o
City/State/Zip: w _i�:kl�Pbone#: 3 _ 3 L164
Are you an employer? Check the appropriate box: Type of project(required):
1.® 1 am a employer with 4. I atm a general contractor and 1
employees(full and/or part-time).
have hired the sub-contractors 6. New construction
1 am a sole proprietor or partner- listed on the attached sheet. 7. ® Remodeling
ship and have no employees These sub-contractors have g. ® Demolition
working for me in an capacity. employees and have workers'
� Y P' Y. 9. ® Building addition
[No workers' comp. insurance comp. insurance.,
required.] 5. ® We are a corporation and its 10.0 Electrical repairs or additions
3.® 1 am a horneovtiner doing all work officers have exercised their 11. Plumbing repairs or additions
[No workers
myself. ' comP. right of exemption per MGL
Y
12.0
insurance required.] T c. 152, §1(4),and we have no 12 ® Raofrepairs
employees. [No workers' 13.0 Other _
comp. insurance required.]
*Any applicant that checks box 41 must also till out the section below showing their workers compensation policy information.
t tlomcowxners who submit this affidavit indicating the}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 name of the sub-contractors and state whether or not those entities have
employees. WOW sub-contractors have employees.they must provide their workers comp.policy number.
I am an employer that is providing workers'compensation insurance./or my,emplgvees. Below is the policy and job site
information.
Insurance Company Name:_
Policy# or Self-ins. Lic. #: _ i Expiration Date:_
.lob 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,504.04 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby ce under �zd penalties ref perjury that the information provided above is true and correct.
Si nat Date: '*_51 z-
Phone#: ze
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
Contact Person: Phone#:
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: _'1_1
The debris will be transported by: .60
The debris will be received by: LO - Pjgv6w
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
OW