36-206 (9) 59 WINTERBERRY LN BP-2017-0069
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-206 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-2017-0069
Project# JS-2017-000126
Est.Cost:$50000.00
Fee; $325.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MATTHEW WEST 078279
Lot Size(sq. ft.): 45738.00 Owner: CARLAN MARGARET A&JOVAN JAMES
Zoning: Applicant: MATTHEW WEST
AT: 59 WINTERBERRY LN
Applicant Address: Phone: Insurance:
P O BOX 235 (413) 588-4231
CO N WAYMA01341 ISSUED ON:7/22/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL BATHROOM,REMOVE NON
BEARING WALLS
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 14 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 Si¢nature:
FeeType: Date Paid: Amount:
Building 7/22/2016 0:00:00 $325.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0069
APPLICANT/CONTACT PERSON MATTHEW WEST
ADDRESS/PHONE P O BOX 235 CONWAY01341 (413)588-4231
PROPERTY LOCATION 59 WINTERBERRY LN
MAP 36 PARCEL 206 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid G d. 'd'
Building Permit Filled out
Fee Paid
Tvoeof Construction: REMODEL BATHROOM,REMOVE NON BEARING WALLS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 078279 � ,�j�
3 sets of Plans/Plot Plan / lirieco#y/o Q-.PS'
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOR 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
Demolition Delay
ignature of Buil.mg 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
1 — City of Northampton
ji 15 2016 BuiStatus of Permit:
ldingent
Curb Cut/Driveway Pemul
212 MainDepartmStreet Sewer/Septic Availability
DEP
suLLnz:c earrx�iorvl Room 100 Water/Well Availability
NORTHAMPTON,MA 01060orthampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 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 be completed by office
Si u. „}mrberey Ln- Map Lot Unit
fleo'+,n.-t / NI, 6•o67-
Zone Overlay District
Elm SL District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
.St,•sJ ,S i.e.( 51 WhkI$.0 r7 let tlort.nc<. Mot 01°42
Name(Print) Current Mailing Address.
— , MI3 714 3411
Telephone
Signature
2.2 Authorized� Agent: 19 -7
M4- W)JiS} Po 00JL Zit Con 4"t) 1 VW, 0410
NamCurrent Mailing Address:
es(Print)gickh- tta 5-as Y231
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 330 opt. (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
4
1/0i OOD _ Construction from(6)
3. Plumbing /), 00C) Building Permit Fee 2 {l'
4. Mechanical(HVAC) v v
5. Fire Protection
6. Total=(1 +2+3+4+5) . 45V1oOa Check Number gt<3
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
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
This column to be filled in by
Building Depvm,mt
Lot Size
Frontage
Setbacks Front
Side L: R: L:
/
X77: .
Rear \
Building Height \\11
Bldg.Square Footage %
Open Space Footage % I
(Lot area minus bldg&paved
parking)
#of Parking Sp..-s
Fill' /J
olmne&Location)
A. Has a S eclat Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT 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 O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O 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? YES O NO •
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 ❑ Replacement Windows Alteration(s) ® Roofing n
Or Doors El
Accessory Bldg. ❑ Demolition [] New Signs [CO Decks [(] Siding 101 Other[01
Work:Onnwiption(+Proposed
t f\m e1 knyllelreo"P 11,5 tflevtov1tns nonl«.�l 6.wjn5 wally
Alteration of existing bedroom St• Yes No Adding new bedroom Yes bk No
Attached Narrative Renovating unfinished basement Yes x No
Plans Attached Roll -Sheet
Ba.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. s mensions
e. Number of stories? ,
f. Method of heating? ` - Fireplaces or W oodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within r. .of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of ba • -nt or cellar floor below finished grade
k. Will • ',ling conform to the Building and Zoning regulations? Yes No.
I. eptic Tank_ City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Ti V bIM45 ,as Owner of the subject
property 11 I
hereby authorize IW44I_ ryI54--
to act on my behalf, in all matters relative to work authorized by this building permit application.
7//3/ / 6
Signature of Owner / Date
I,
illicit-1-4 +r ,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.
lyg WL�f
Print Name
okt ` /31[6
Signature of Owner/Agent ate
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction/Suprr
e `visor: 1_ '' 1 Not Applicable 0
Name of License Holder: ''`kk(yIkcA E •WIJ 01t179
License Number
Po tzox G, nth 01111) 2/s/ i�
Address I Expiration bate
V'�alfU/,ILhrlre'
1413 SSB V23)
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable 0
MA i.1.-/ E wL5c- /so 6 5.C-
Company Name Registration Number
1930 5t bwi c-F^ks Izc) ConI_a. 1 Kt, 0)341 1211)/za6
Address Expiration Date
Telephoneyf3rl 4231
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 14. No 0
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 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
c Mita99b Office of Investigations
kat,. 4 I Congress Street,Suite 100
-' ll- Boston, MA 02114-2017
`'W� www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information kA 'I, Val--
Address:
/1 Please Print Legibly
Name(Business/Organization/Individual): ` 1A4I Uc$f
Address: PP. Pox 2.35
City/State/Zip: Co'slat hn..t o/7N( Phone#: y13 SSS `1231
Are you an employer?Check the appropriate box: Type of project(required):
L❑ 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
listed on the attached sheet. 7. Remodeling
2.n I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g. a Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.[ 9. LI Building addition
required.] 5. ❑ We are a corporation and its 10.1E Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I L(Phunbing repairs or additions
myself [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.]` c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box al mom also fill out the section below showing their workers compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such,
:Contracton 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'comppolicy 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:
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$1,500.00 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 ccate�atlIrtify underI the pains and penalties of perjury,that the information providedddabovebis true and correct
signature: I,I/YrVtt yv"n Date: /13/ "d
Phone#: tin SES NL31 iii
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: PermitfLicense#
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: 51 Wi,4tc ,c.rn 1 L h
The debris will be transported by: AoSt n 45
The debris will be received by:
Building permit number:
Name of Permit Applicant (11MW ASF
'Val /6 AriA4-t
Date Signature of Permit Applicant