17D-026 (4) 77 STRAW AVE BP-2016-1324
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D-026 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit# BP-2016-1324
Project# JS-2016-002286
Est. Cost: $3000.00
Fee:$65.00 PERMISSION I HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ANDREW T WALSH JR 082029
Lot Size(sq. ft.): 16335.00 Owner: NAYAK ANAND P& POLLY FIVEASH
Zoning: URB(100)/ Applicant: NAYAK ANAND P & POLLY FIVEASH
AT: 77 STRAW AVE
Applicant Address: Phone: Insurance:
77 STRAW AVE
FLORENCEMA01062 ISSUED ON:5/16/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 16 X 15 DECK
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Undergreuind: Service: Meter:
Footings: f I
Rough: Rough: House# Foundation: S p rye--i)1.2-e0
Driveway Final:
Final: Final:
Rough Frame: c-orr` K.
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: 6-f-
THIS PERMIT MAY BE REVOKED BY THE ITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS ZZ7
O S.Certificate of Signature: LLLL//// d-'U.Lp !I c" .2"11("(--L
FeeType: Date Paid: Amount:
l3uilding 5/16/2016 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
File# BP-2016-1324
APPLICANTJCONTACT PERSON NAYAK ANAND P&POLLY FIVEASH
ADDRESS/PHONE 77 STRAW AVE FLORENCE01062
PROPERTY LOCATION 77 STRAW AVE
MAP1�7 PARCEL 026 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL U$E ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM OUT r,.,
Fee Paid / bSt
Building Permit Filled out
Fee Paid
Tvpeof Construction: CONSTRUCT 16 X 15 DECK
New Construction
Non Structural interior renovations
Addition to Esist(pe
Accessory Structure
Building Plans Included:
Owner/Statement Statement or License 082029
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
E/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
Demolition Delay
Signature of Building Official 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.
Department use only
IN/CO , City of Northampton Status of Permd
Building Department Curb Cut/Driveway Permit
C� 212 Main Street Sewer/Septic Availability
{ Ill Room 100 Water/Well Availability
-miemice_a_______
Northampton, MA 01060 Two Sets of Structural Plans
I it µ°N°� -587-1240 Fax 4'13-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to becompleted.by office
11- S 7'--M- w Al--"e- Map Lot Unit
• .VO NC.— Ata. Of O 62
Zone Overlay District
Tc
i
FIm St.Dstrict CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
• aIC - 1 S-E'wW 4....,... r'—(ore»t a,,/t& , Ctu6,4
Na . •Pri 000,• Current Mailing Address' C / �I
4 .....,_..4't„•!,..1--, Telephone 51/ �O D �� To
:!atur
2.2 Authorize•gent:
*/%%ACy GE
Act••cLet.J T. Luc. lSI, (;)-0/ aex 6os19 010642.
Name(Pont) Current Mailing Address: r
� V • LiA. 1-1-I3 - 51D - 1 1 Q
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
3, OOO. O o
2. Electrical (b) Estimated Total Cost of
Construction from(6) 3, 4 cJr�
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection St
6. Total=(1 +2+3+4+5) ,Check Number /93 i SWS
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING Alt Information Must ee Completed,Permit Can Be Denied Due To Incomplete Information
Existing I Proposed Required by Zoning — .
dim cokunnl be filled in by Wit I
Building eepamneno
lip
Lot Size
Frontage _.. . ...
Setbacks Front
Side
Rear
Building Height
_ s
Bldg.Square Footage I" %
Open Space Footage ._ % _. .
(Lot area minus bldg&paved '_.. _. . _. .
Palling)
#of Parking Spacess _ .. _ . .. to >' .• T'C.:.;t+'
f. . s
Fill; -. .__
(volume&Location) __. __.__ ...... ,__.
`''`tt' Alias; Special Permit/ ariance/Finding ever been issued for/on the site?
' , 1 ' e r-
10 Q' DINT KNOW r YES Q n .. .
.
1F YES, date issued:, - ,
_. _. t,'
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES 0
IF YES: enter Book Page and/or Document
#.._.
6. Does the site contain a brook, body of water or wetlands? NO • DONT IRIOW. Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
........... . . ... .......
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO
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 '4_J
IF YES, describe size, type and location:
E Will the construction activity disturb(clearing,grading,excavat n, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO �
IF YES,then a Northampton Storm Water Management Permit from the DPW is reunited
•
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
1
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing
Or Doors ED
Accessory Bldg. ❑ Demolition U New Signs [CI Decks [ier7 Siding[OI Other[CA
Brief Description of Proposed
Work: 6rX IS The lc. c.*' aa,- 1aw(a. ( i4 ce..<. 0-91,4))
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes 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 Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms.,,,,
e 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 1001t.of wetlands? Yes No, Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar Boor 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
as Owner of the subject
property
hereby authorize .._to act on my behalf,in all matters relative lc work authorized by this building permit application.
Signature of Owner Date
I, , 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
Signature of OwnertAgant Date
t
SECTION 8•CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable I
Name of Licence Holder: i(aa% —
License Number /10
Address Expiration Oat..
Signature Telephone
9 Registered Home Improvement Contractor Not Applicable £ / g�
Company Name Registration Number"p�~-
/3.37.771‘"
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. E.
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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$unreowner: 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
sintctures.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 hefshe 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 injurtes not resulting in Death)of the Massachusetts General Laws fvumtated,you may be liable for person(s)
you hire to perforin work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,Sta. os p' s and State of Massachusetts General Laws Annotated.
Pii Homeowner Signature -egg._ / •_
City of Northampton
�CLr� s 'rr, s/
Lit
Massachusetts
, hhh
t.
� � DEPARTMENT OF BUILDING INSPECTIONS T
' T.
212 Main Street a Municipal Building
Northampton, MA 02060pn ycy
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.1 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
jbefore 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 insp ions are made
1, '
4t.. _ understand the above_
(Home wner Ire l n ' signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date Cj i 3 ) 1 b
Address of work location 1 3 .c4-v"^.) Ave
k'LDve,� cer ts, 0 0, 4a
-4The Commonwealth of Massachusetts
Department oflndnsnrial Accidents
,.h, Office of Investigations
S h 600 Washington Street
`-^' '� Boston, MA 02111
F'- 60
< s6B wwev.rnass.gov/tdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information (� �^- / (� Please Print Legibly
Name (BusincssiOrganizatioi4ndividual). Au{Yv& j V _Leal 114 J`'- A-b.4Pc. t LJ'aT,✓v U},k5
Address: Q-b, a0> 6 (:). S ( el I
City/state/zip: 'S-"1;hiew ca vAA4. Ct o £.I) Phone#: 4 ! 3 - 5 ),2 - 1 4 q
Are you an employer? Check the appropriate box: Type of roject(required):
1.❑ I am a employer with 4. 0 I am a general contractor and I
employees(full and/or part-time).
have hired the sub-contractors ti. New construction
2.P.I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
workingfor me in anycapacity. employees and have workers'
V t3' 9, ❑ Building addition
[No workers' comp. insurance comp. insurance.]
required.] 5. 0 We are a corporation and its 10.j Electrical repairs or additions
3.7 I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself [No workers' comp. right of exemption per MOL 12.❑ Roof repairs
insurance required.] t c, 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
"Any applicant that checks box#1 must also all out the section below showing their workers'compensation policy information,
4-10 meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tConnactors 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 employers,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. Lie. #: 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
tine 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 under the pains and penalties ofperjury that the information provided above is true and correct.
,signature: , �.�xI\. Date: Si 131 ( 1.2
Phone#: d'f 1 3 — S 11 — 14 ci 5
Official use only. Do not write in this area, to he 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 1`orthampton 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: S. •-c". L4,, AL t--(L)veci ✓tc . 0jC62.
The debris will be transported by: 7-tw Li J(...( S LI
The debris will be received by: U.,t7, e e c, c-t ;p 5
Building permit number: ..._.
Name of Permit Applicant Av1/40-,^k. 1VayaL-
Date ignature of Permit Applicant
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