23D-124 (15) 176 FEDERAL ST BP-2017-0137
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23D- 124 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 4 BP-2017-0137
Project# JS-2017-000221
Est. Cost: $6800.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Cta(s:, Contractor: License:
Use Group: JAMES O'SULLIVAN 66335
Lot Size(sq,ft): 20952.36 Owner: TRINIDADE BRUNO
fl1001/ Applicant: JAMES O'SULLIVAN
AT: 176 FEDERAL ST
Applicant Address: Phone: Insurance:
264 BUCK POND RD (413) 532-1312
WESTFIELDMA01065 ISSUED ON:811/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:ENCLOSE PORCH TO MUDROOM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector f 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:
FceTvpe: Date Paid: Amount:
Building 8/1/20160:0400 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0137
APPLICANT/CONTACT PERSON JAMES O'SULLIVAN
ADDRESS/PHONE 264 BUCK POND RD WESTFIELD01085(413)532-1312
PROPERTY LOCATION 176 FEDERAL ST
MAP 23D PARCEL 124 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT „y�
Fee Paid / V #41
Building Permit Filled out
Fee Paid
Typeof Construction: ENCLOSE PORCH TO MUDROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 66335
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
Demolition Delay /
tVi
Signa re . :uil n 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.
RECEIVED
Deparbnent use only
• City of Northampton Status of Permit:
A - 12016 Building Department Curb CullDmlewey Permit
212 Main Street Sewer/Septic Availability
.OF BUILDING INSPECTORS Room 100 Water/Well Availability
NORTHAMPTON.MA O.00 Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-5B7-1272 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 be completed by office
-4 S m Map Lot Una
(S NC t lM rA Zone Overlay District
T Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Al A-CrEe euub vht' nix -t-EZ>LR-dpi- Sr
Name(Print) Current Mailing Address:
sNle LG�tL- lol� SLS
Telephone l�7z_V
Signature
2.2 Authorized Agent:
W1N 24 V3nR01\,� 4 wLc5T
Name(Print Current Mailing Address: (�10s�
`_\\J 413— S32-I 3)2—
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building L/Q c 0 CO (a)Building Permit Fee
2. Electrical s^ o,CO (b)Estimated Total Cost of
o Construction fmm(6)
I Plumbing Building Permit Fee
4 Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) ( qU( OOCS Check Number "*,
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissionerflnspectar of Buildings Date
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information t
Existing Proposed Required by Zoning
This column to be filled in by
Building Department t
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
R of Parking Spaces
Fill:
polume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO NT KNO YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands?(NO5 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 C
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradin• excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check an aputicabie)
New House Addition Replacement Windows AlteratIonfa) Roofing
Or Doors
Accessory Bldg. Demolition New Signs [ ] Decks [ ] S{dlng[� Other[ [
Brief Description of Proposed 71 a Cor SNS+ciffi._.
Work. 4iUl L7? MCD C'Cr`idA ON FA (Sri Ai fo€4,6, '1.7411/41I5+ 7r nitro it, 5 irvj
Alteration of existing bedroom Yes ?C No Adding new bedroom Yes v`No
Attached Narrative Renovating unfinished basement , Yes )( ,No
Plans Attached Roll -Sheet
at it New house end or addition to existing housing.Oomolete the following:
a. Use of building-:One Family 1111'— Two Family Other
b. Number of rooms in each family unit: 7 Number of Bathrooms —2--
c
c. Is there a garage attached? Nb
5.r 7 C Coi
d. Proposed Square footage of new construction. Ho- Dimensions
e. Number of stories? r ��
f. Method of heating? `Gly/- Y�?inlF1(sI H Fireplaces or Woodstoves Lab Number of each
g. Energy Conservation Compliance. Maascheck Energy Compliance form attached?
h. Type of construction WmTD
i. Is construction within 100 ft.of wetlands? Yes PC.,No. Is construction within 109 yr, floodplain Yes OC,No
I. Depth of basement or cellar'loot bebw finished grade v—
k. Will building conform to the Building and Zoning regulations? QC Yes No.
I. Septic Tank City Sewer 1-- Private well City water Supply ."--
SECTION
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
t A/i ti 1},- f--Cre ,as Owner of the subject
property ]67%)‘56/0
A /� ,..,�
hereby authorize J°ITT7)q /0 { \ S/O-UC-f (C�e"')
to act on my behalf, I a matters rotative to work authorized by this building permit application.
rLMA. �-- &'—(-14
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 the pains and penalties of perjury.
> S aSet NAN
Print Na Cq v ( /� 4
ay\F\Orme 1 Y
Signature r/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Constructionn Supervisor: Not Applicable ❑
tame of license Holder' C1 Pt'ME—S OSUIIt VJ1✓J 'VC2 33 S
License Nu
.2-Ce4 �ilc K�.r e.11 CLIA Z1 )7
Atltli�a �Sr�t�.ti� Vv,A- (31o)S5 Eiwiraeen Date
4-N3 -S3z- 1.3t
Signature Telephone
R Rsaistered Home Improvement Contractor: Not Applicable ❑
NV) K1)Is� N 6 �sce (Oev 1456 'fO
Company Name Registration Number
7 La 4 3 Y-')Ots'i Z—/(o
Address Expiration Date
W cST('cl_� M Y - C 16(f'S Telephone 4 13
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e.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 yv� 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 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 fans
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 ycu 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
The Commonwealth of Massachusetts
tt��
:m== Department of Industrial Accidents
ly=L_j1= L Office of Investigations
_
el— 1 Congress Street,Suite 100
—_"�
• '- Boston, MA 02114-2017
s www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizatiodlndividual): ONf:1)1 CCv1 CCN CSTP 1107OIK) _
Address: 2LR (f -(43CIL R bed h R-
City/State/Zip: W ES,TcleF\> 6M0- Phone#: 'S32- r-\3 12—
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 I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2. 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
workingfor me in anycapacity. employees and have workers'
P t3'' 9. ❑Building addition
[No workers' comp.insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.0 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 1g❑Roof repairs
insurance required.] ' c.152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
*My applicant that checks box#i must also fill out the section below showing their workers'compensation policy information.
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 name 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.
1 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
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 5250.00 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 cce fy and the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: 6 " —I 0
Phone#: et)3-5-i1-431z
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 150k
Address of the work: VVI •;?—A-t— S\ c(A25NCE_ Y \
The debris will be transported by: t Y y-i---)(s3N CON STR_oc'i o�
The debris will be received by: \34*L--\J R&cs1LL r'
Building permit number: 11 1
Name of Permit Applicant OrnES Ati
f( ia �
Date Signature of Permit Applicant
I
AffoJ y'4ot &hart_
Astu.J Jiunaw I 7'X L,' ', d
'y yr ,-;-: M1>'_ J�J �
„, cic .1. 1 TELA li erit_ Ntv- Z74Lc v.✓,L - 'i'l
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-'77Z7-77),.._- �X Z 21 of ____.._.,-'-
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City of Northampton
Building Department
Plan Review
212 Main Street
Northampton, MA 01060
fe,massDOT
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