25A-031 (2) 80 CROSBY ST BP-2016-1140
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A-031 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-1140
Project# JS-2016-001959
Est. Cost: $40000.00
Fee: $260.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DANIEL HEWINS 049714
Lot Size(sq. ft.): 16509.24 Owner: MACKIEWIC4 WILLIAM D&JOANNE
Zoning: URB(100)/ Applicant: DANIEL HIEWINS
AT. 80 CROSBY ST
Applicant Address: Phone: Insurance:
P O BOX 186 (41�) 582-9929
CHESTERFIELDMA01012 ISSUED ON:3/28/20160:00:00
TO PERFORM THE FOLLOWING WORK.-RENOVATE 2ND FLR, ADD 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 CITY1 OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 3/28/2016 0:00:00 $260.00
212 Main Street,Phone(413)5�7-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
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File#BP-2016-1140
APPLICANT/CONTACT PERSON DANIEL HEWINS
ADDRESS/PHONE P O BOX 186 CHESTERFIELD01012 k413)582-9929
PROPERTY LOCATION 80 CROSBY ST
MAP 25A PARCEL 031 001 ZONE URB000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Pain _
Building Permit Filled out
Fee Paid
Typeof Construction: RENOVATE 2ND FLR ADD BATHRQOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 049714
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON TRIS APPLICATION BASED ON
I)Fqp,RMION PRESENTED:
Loo'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
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ig e of uDate
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.
. ......J)
ity of Northampton Status of Perx.n�ttN� ""
91 �k;w,. ,�s y ;LL l�W�r�'NS
juilding Department ct�rIa Cut/Dr11Le�1tla ,Pyerlrtt# ;^h �r {
WRWR :n i 6� K;} x
2 v ; � 212 Main Street SsWe .Sebt7cAva4fafijltty � Y��. �, „� �,A , yY
Room 100 Nat r%Y/1etAuatlaCillity�,
�IYIN
oe�r Northampton, MA 01060 Tv�o15�fifid ste'. ,tenial Pta€rs n ?�
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- #one 413-587-1240 Fax 413-587-1272 Plaf/Sit�Pians k k P �(� 21hY E" '
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Outer pecik,
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APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
lg- pi
This section to be completed by office
1.1 Property Address: p pp -
g40 C N Q S U YMap F Lot Umt
Zone -� Overlay District � _
EIm St Dtstnct -::: ;�; CB Distract ;r,
SECTION 2. PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
6 , z. c r JyAtjJ A ty
Name(Print) f Current Mailing Address:
(Telephone
Signature
2.2 Authorized Agent:
DAr f E-fE,PJirs PO 30f RFhL.D
Name(Print) (Current Mailing Address: 1 d I Z
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 3 rl Q O U (a) Building Permit Fee
2. Electrical (b)Estimated Total Cost of
o Construction'from 6
3. Plumbing 0 17 O ', Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) 0 0 0 0Check Number
This Section For Og ficial Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissionedin.spector'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 J
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&payed
#of Parking Spaces
(volume&Location)
A. Has a SppciaLPermit/Variance/Rnding ever been issued for/onthe site?
^�& x�� �~t
NO K�J DON7KNO�/ «*� YES v�/ �
'
IF YES, date issued:!
IF YES: Was the permit recorded atthe Registry ofDeeds?
0
NO DONT KNOW 0 /c»
IF YES: enter Book Page and/or Document#
�� ��
O. Does the� ��tecontainabrook, body NO ��/ DONTKNO\� «�� YES «��
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained «~� Obtained »�� Date Issued:
�°� �~� '
C. Duany signs exist onthe property? YES K 1 NO
IF YES, describe size' type and location:
D. Arethereanypropusedchangestuuroddidonsofsignsintendedforiheproperty7 YES 0 NO QK
|FYES, describe size, type andlocation:
E. Will the construction activity disturb(clearing,gradingUon.orfilling)over 1acre nrimitpart ofacommon plan
thu�*iUdia(urbover1 acre? YES � � NO Kw�
' v~� ~_~
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all app!icable)
New House F-1Addition ❑ Replacement Windows Alteration(s) ❑ Roofing El
Or Doors !]
Accessory Bldg. ❑ Demolition ❑ New Signs CD] Decks [d Siding[O] Other[
Brief Description of Proposed (> J AT tN r� N D D (� ATH 9004,
Work: [�.• f l� /
Alteration of existing bedroom Yes No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
r__ N.., �., �,.
6a If'New house and or=addition to exisfina h"ousina; ornplete 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. Ma$scheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes NG. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor bel finished grade
k. Will building conform to the Buildi 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, 9 1 /- L Ih Lx /E w/ Gz as Owner of the subject
property
hereby authorize L W,
to act on my behalf, in II atters relative to work authorized by this bu Iding permit application.
Signature of Owner Date
as Owner/ ut
ge ereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
bntrbelief.
Signed under the ains and penalties of perjury.
Print Name
L) -7
Signature of Owne Agent Date
A
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: { Not Applicable
�- £
Name of License Holder: D I L (? W I f"�, � `h 1 7 (
License Number
PO fax 1 � C FF �ST a.FfF�b� \ A off ( IZ G /z„o ib
Address Expiration Date
'\ 1 0 ! !
Signat Telephone
9::Registered Hame Improvement Contractor.. ri _ .,... Not Applicable £
pArll ,6L 1 -77697
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...... £
11. . ,Home Owner Txeml)tion
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.
AIso 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 I A
The Commonwealth of Massachusetts
Department of Industrial Accidents
f Office of Investigations
600 Washington Street
Boston,AL4 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information _l '' / Please Print Legibly
Name (Business/Organization/Individual): r 1 L 4 6 w t) 7
Address:
City/State/Zip: C P4� 5 T,!�rc F 1 k'L b 4 i o l Z Phone#:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction
mployees (full and/or part-time).* have hired the sub-contractors
2.ry I am a sole proprietor or partner- listed on the attached sheet. 7. 5alemodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for mein any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the nate of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$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.
I do hereby certify the pains and penalties ofperjury that the information provided above is true and correct.
Signature: Date: -3 1
Phone#• 2, Q
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 j
Massachusetts
{ �r DEPARTMENT OF BUILDING INSPECTIONS �S x
x„ 212 Main Street • Municipal Building
�" ,• ' Northampton, MA 01060
- jY S+7
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 any 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 occupancy 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 permits 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 /A
I, 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
. i
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: Q C °�' QY
The debris will be transported by: k,A (,-Tg
The debris will be received by: V L G E Y GY C L C
Building permit number:
Name of Permit Applicant �'� I H E w
3
Date Signature of Permit Applicant
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