42-091 (3) 206 GLENDALE RD BP-2017-0853
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 42-091 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: New Single Family House BUILDING PERMIT
Permit# BP-2017-0853
Project# JS-2017-001431
Est.Cost: $150000.00
Fee: $1303.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
use Gronp: Homeowner as Contractor
Lot Size(sq.ft.): 33018.46 Owner: ANDREW WRIGHT
Zoning: Applicant: ANDREW WRIGHT
AT: 206 GLENDALE RD
Applicant Address: Phone: Insurance:
231 SOUTHAMPTON RD (413) 695-5495
WESTHAMPTONMA ISSUED ON:1/23/20170:00:00
TO PERFORM THE FOLLOWING WORILDEMO EXISTING BUILDING, BUILD NEW
SFHOUSE
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 1/23/2017 0:00:00 $1303.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0853
APPLICANT/CONTACT PERSON ANDREW WRIGHT
ADDRESS/PHONE 231 SOUTHAMPTON RD WESTHAMPTON (413)695-5495
PROPERTY LOCATION 206 GLENDALE RD
MAP 42 PARCEL 091 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
-•CLOSED REQUIRED DATE
ZONING FORM FILLED OUT alk
Fee Paid Aron
Buildin_Permit Filled out at
Fee Paid Mar
T serif Construction: DEMO EXISTING B 'BUILD NEW SFHOUSE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
proved 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: §
FindingSpecial 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 Dela
f /— 2
re of Building 0 ricial 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.
- fli
City of Northampton ,stoGtp offgAlllt
Building Department ;CwkCW it
212 Main Street
Room 100
Northampton, MA 01060 TMOMOMof
phone 413-587-1240 Fax 413-587-1272 P .
f�tltar Spsr9ty
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION FI2c- . c aC
1.1 prooefty Address: X)C jier --tL i t� This section to be completed by office
�-/pr 4Ge I/�6'5 ( O/Ogd Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Ar L„, C„p;3i•ef &ukkeee.to \ ASI ,e 114-p/0„/,fly?
Name lPn, /MOSS
SSfailingfl(&Jh
� . Telephone t// S
3 _b y3 l 71
grmture //
2.2 Authorized Mont:
Name(Print) Current Mailing Address'
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (3 °C)C ,y (a)Building Permit Fee
2. Electrical / (b)(b)Estimated Total Cost of
(2 tl Construction from(6)
3. Plumbing / Building Permit Fee
4. Mechanical (HVAC)
5.Fire Protection f ^¶4 CC) \\
6. Total=(1 +2 +3+4+5) /1 � Check NumberEt, 3.03
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building CommissionertInspector of Buildings Date
SECTION Se DESCRIPTION OF PROPOSED WORK(check all aDellcable)
\New House 1 Addition Replacement Windows Alteration(s) Roofing
_.. Or Doors
Accessory Bldg. Demolition New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Work�suiption of Proposed l.„}-emo 2Xf S{rr) f t 34, fai f Hi.w $ r , rj
Alteration of existing bedroom Yes No Adding new bedroom Yes J No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Se.If New house and or additionito existing housing, complete the following:
a. Use of building : One Family Two Family Other r�
b. Number of rooms in each family unit: Number of Bathrooms .c-
c. Is there a garage attached? NC) ,/ L{/_'
d, Proposed Square footage of new construction. rry :�j� Dimensions LJ n `C)
e. Number of stories? /' 1' r
f. Method of heating? �4S + ''` C o Fireplaces or Woodstoves nCA P 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�/
j. Depth of basement or cellar floor below finished grade
k. Will building confo' orrm to the Building and Zoning regulations? / Yes No
I. Septic Tank _ City Sewer Private well City water Supply ]
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i. Ar1c‘CC Cis.ice) ,as Ovmer of the subject
properly
hereby authorize
to act onr�ty behalf,
.' alive to work authorized by this building permit application.
'r attire of a er 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 Owner/Agent Date
Section 4. ZONING Ail Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
f"his column to be filled in by
!! Y' ������..„„.ryy Building Departmem
Lot Size A�fUX--s/l/� ... .._
Frontage l90` .._ .. . . ...
Setbacks Front Ci ._.; .....
Sig L: GS R: AY L.: R: .....
Refit 10�
Building Height Y$_..., _...
Bldg.Square Footage aoo SOO
Open Space Footage °!o
(Lot area minus bldg&paved
parking)
#of Parking Spaces 1.fie.. . _..._
Fill: _._.. m .__ ._. _.... .... _._ .. _.
(volume&Location)
A. Has a Special Permit/Vari ce/Finding ever been issued for/on the site?
NO DONT KN 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 d
B. Does the site contain a brook, body of water or wetlands? NO 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 NO
IF YES, describe size, type and Location:
E. Will the construction activity disturb(clearing, cavation, or filling)over 1 acre or is it part of a common plan
that will disturb over t acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 8-CONSTRUCTION SERVICES
8.1 LicenSad Construction Supervisor: Not Applicable 0
Name of I Wenn Holder:_
License Number
'_
Address Expiration Date
Signature Telephone
S.Registered Home Improvement Contractor: Not Applicable O
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 ❑ i
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(be owner acts
gs sunervisor.CMR 780, Sixth Edition Section 108.35.1
pefinitioa 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 coasts-nets 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 thebuilding 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 perioral work for you under this pemtit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State a al Zoni f sand State of Massachusetts General Laws Annotated.
Homeowner Mannar /eK
/ `-
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: C( ct�ti,l
enc( .I e g
The debris will be transported by: A SA P
The debris will be received by: (Agri fcc 4-
Building permit number: _,
Name of Permit Applicant Ancl1cL-
/- V-17
G ��
Date —Signature of Permit Applicant
The Commonwealth of Massachusetts
PAL(' - Department of Industrial Accidents
JA= x ice of Investigations
'
_ i: a 1 Congress Street,Suite 100
1li` Boston,MA 02114-2017
44,
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone 14:
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
6. ❑New construction
employees(full andtor part-time).* have hired the sub-contractors
2.❑ t am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
workingfor me In anycapacity. employees and have workers'
aP ty Q. 0 Building addition
[No workers' comp.insurance comp.insurance.:
,r aired] 5. ❑ We area corporation and its 10.0 Electrical repairs or additions
3. am a homeowner doing all work officers have exercised their 11.0 Plumbing 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 hat checks box#1 must 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.
:Contractors that check this box must attached an additional sheet showing the name of the subAconbactors and state whether or nm those entities have
employees. If the sub-contactors 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, 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 e. 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 DR for insurance coverage verification.
I do hereby cemjy under di- vsins and penalties of perjury that the information provided above is true and correct.
Si,1at L': _..,. Date: J-1/-/7
_..,._
Phone#
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requites all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as`...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual.parharship, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has notproduced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s)name(s),address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town flat the application for the permit or license is being requested.not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitllicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for fume permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Maecarhrseits
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
Boston, MA 02114-2017
Tel. #617427-4400 ext 7406 or 1-877-MASSAFE
Revised 7-2013 Fax#617-727-7749
www.mass.govidia
City of Northampton
Massachusetts 4,.. °,-
( ke
r of I
sg DEPARTMENT OF BUILDING INSPECTIONS
212 Maln Street • Gun lcipaI au :ding
Northampton, NA 01060
INSPECTOR
Louis Hasbrouck Chuck Meier
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWI EDC,EMENT
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
. .- , • - • • • 'r • _ •.y.1 • - • h• _ • • '• , 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
A1lctrc�. ( .is t S \-''" 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 r—c�'�1
Address of work location dol- ( /er\cic i f
�(o c & (ACC , 3(cd1
Commonwealth of Massachusetts ..��j�/'�j
fr City/Town of Northampton Number
j Application for Disposal System $ Doo
'w Construction Permit Fee
Form 1A
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site
sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and
not to place the system in operation until a Certificate of Compliance has been issued by this Board
Health. -, /'
/ � ' _ S` /2
z-
Aignature - Date
Application Approved By:.//0,
Name j 7 ,;1 / t }+ ' x1 .. Date , / /
N///4W✓
Application Disapproved for the following reasons:
Conditions:
I).System Designer must inspect and verify in writing
Dist the sewage disposal sysicm was installed
b accordance with the approved plans and Title 5.
2).If this is a system with the S.A.S_constructed in
T. itle 5 fill the System Designer must conduct a bottom
nspection of the excavated area prior to the placement
of the fill.
3).No changes catt be made during construction by the
Installer without prior approval by both the System
Designer and the Board o£Hzaith Agent.
aem: turns;
t5formi a.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3
GLENDALE 'ROAD NO-RT -D ON, MASSAC- . SET-S
T.P. # 1
— ,,„.„, ri..
Bev'. 100.00
G.W. None
\ kii: — PA
Er
190' W i
Er
E(T
..( ,
rem-oq at telephone pole-Elev. 100.00 W EjT \y,,
Proposed water lin j �
I .100.00 _ j o
s EfT <
i 2
i \
W EWT
PLAN VIEW \ /
Scale: 1" = 20' U ETV
Area = 57,000 sq. ft. ± AV
Map # 42-091 & 42-094 E1T Proposed
W Utilities
I Pumpout mon-hole ("C" / T.P. # 2
I_ tpl\ Elev: 100.00
G.W. None
pvc solid pipe (Sz.01 min. ) W E T
( /'
Perc test # 1
ct,-ri/'-S'' EiT
poled distribution box- L___L
Te pit # 2 Proposed Garage 1� Y
3 bedroom i t
1 /
w/f house `/.,
I
in
Crit'-'71
(it_ ED
n ❑NrA
00.00
t0
a xisting foot print of house
it i (Existing house to be raised)
ectiion port (E"}/ 'V '— P/L
{ Reserve
area
:' ./) 4%1 1
Perc test # 2..r Existing septic tank (ref_ only)
t
Test pit # (see note # 13)
i s99.00
Telt pit # 4
d xisting SAS (refonly)
(see note # 13)
AS-BUILT DIMENSIONS p
�
!''^� Contractor to take two ties from referenced
T � 'i-1/" points and mark of plan.
�'"' o "C" .B" to 'C'
ffr
o 'D'_ 'C' to 'D'
I f? '`'� to 'E' 'C' to 'E'_ _.
1....__.,_..__ e._ 196' _ PSL.