31D-143 (7) I AMBERLN BP-2017-1461
GIS 0: COMMONWEALTH OF MASSACHUSETTS
Map:Block:31D- 143 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Pennit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2017-1461
Project JS=202015-001514
Est. Cost:
Fee:Moo PERMISSION IS HEREBY GRANTED TO:
Cons(.Class: Contractor: License:
Use Group: DANIEL K DACRI 105989
Lot Size(sq,ft.): 1219.68 Owner: WITHENBURY EMILY
Zoning:CB(100)/ Applicant: DANIEL K DACRI
AT: 1 AMBER LN
Applicant Address: Phone: Insurance:
247 RIVERSIDE DR (617)543-2843 Workers Compensation
FLORENCEMA01062 ISSUED ON:617412017 0:00:00
TO PERFORM THE FOLLOWING WORK:FINISH RENOVATIONS ACCESSIBLE
ENTRANCE
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:
FeeTvpe: Date Paid: Amount:
Building 6/14/2W 7 0:00:00 $0.00
212 Main Street.Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-1461
APPLICANT/CONTACT PERSON DANIEL K DACRI
ADDRESS/PHONE 247 RIVERSIDE DR FLORENCE (617)543-2843
PROPERTY LOCATION I AMBER LN
MAP 3ID PARCEL 143 001 ZONE CB(100)t
THIS SECTION FOR OFFICIAL USE QNLY:,
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid (/�
Building Permit Filled out \
Fee Paid
TvoeofConslmction: FINISH RENOVATIONS ACCESSIBLE ENTRANCE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plaits Included:
Owner/Statement or License 105989
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION 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
CE 17
Signature of 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 fin-more information.
- — Versionl.7 Commercial Building Permit May 15, 2000
- I Department use only
City of Northampton Status of Permit
juti (4 Building Department Curb Cut/Driveway Permit
- g } 212 Main Street Sewer/Septic Availability
_ Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
- phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER/tf`i"THHANNA ONE OR TWO FAMILY DWELLING�^}
SECTION 1 SITE INFORMATION "jLI' fr+ I d Oak /5~ S
1.1 Property Address: This section to be completed by office
_.. __..
I d,w a Lu Map Lot Unit
101 i row) Ma O/o&o Zone Overlay District
-- -- - -- - --- Elm St.District CB District
SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) eCurrent Mailing Address
- - Wihher�bu --
17 Hoo�pP ,4Uc, No�tctc�xp+ rl 0locop
Signature /.. n may`se / I. • Telephone
2.2 Authorized Ag-': r i
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 '140141941—
i- 1941— le 00O = (a) Building Permit Fee
2_ Electrical q (b)Estimated Total Cost of
7/ 00(] Construction from 6
—
3. Plumbing Pt(000 Building Permit Fee
4. Mechanical(HVAC) 1000 _—
5. Fire Protection _ . _.
6. Total=(1 +2+3+4#5) 311000 % DODCheck Number gvy� 13.111
_ This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
r
Version I.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations /Existing Wait Signs 0 Demolition Repairs 0 Additions 0 Accessory Building 0
Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing Change of Use❑ Other 0
Brief Description Enter a brief description here. ' •
Of Proposed Work: coot C* &CE - Fna& i 1Zf WY>VRT‘6116i. 4CCESSf Kid £M�'a'I
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 0 A-2 0 A-3 0 1A 0
A-4 0 A-5 0 18 ❑
B Business 1 2A ❑
E Educational ❑ 2B ET-
F Factor 0 F-1 0 F-2 ❑ 2C ❑
H High Hazard 0 3A ❑
I Institutional 0 I-1 ❑ I-2 0 1-3 0 I 3B El
M Mercantile ❑ 4 ❑
R Residential 0 R-1 0 R-2 ❑ R-3 ❑ 5A 0
S Storage ❑ S-1 0 5-2 0 58 ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify: - -
S Special Use 0 Specify
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND(OR CHANGE IN USE
Existing Use Group _-.. .. _ _I Proposed Use Group _. .._... .._.. .. ...
Existing Hazard Index 780 CMR 34): ._.. .._ Proposed Hazard Index 780 CMR 34) _.. . . ... _.
SECTION 6 BUILDING HEIGHT AND AREA �—
BUILDING AREA EXISTING PROPOSED NEW CONS RUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
Il vdQ
4
th I
4in
Total Area(sf) Total Proposed New Construction Jsff
Total Height(ft)
Total Height ft
7.Water Supply(Kat c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public Private Zone:- -- ,. Outside Flood Zone❑ Municipal D On site disposal system
Version]7 Commercial Building Permit May 15,2000
8. NORTHAMPION ZONING
Existing Proposed Required by Zoning
This column to be filled b by
Building Department
Lot Size
Frontage _.. _. -. - ..
Setbacks Front --- "
Side
Rear - .) .....
Building Height
Bldg-Square Footage
Open Space Footage
(Lotureamnasbldg&paved
oada:ng)
of Parking Spaces . ._ .
(interne limped) -."__ _...._ ... .._.
A, Has a Special Permit/Variance/Findi ever been is ed for/on the site?
NO Q DONT KNOW YE 0
IF YES, date issued:
IF YES: Was the permit recor ed at the Registry of Deeds?
NO Q •#NT KNOW Q YES ill
IF YES: enter Book Page and/or Document e
B. Does the site contai a brook, body of water or wetlands? NO +` DONT KNOW 0 YES Q
IF YES, has a p rmit been or need to be obtained from the Conse ation Commission?
Needs to be obtained Q Obtained Q , D. e Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location - --"- -
D. Are there any proposed changes to or additions of signs intended for the prop-rty? YES Q NO Q
IF YES, describe size, type and location. '
E. Will the construction activity disturb(clearing,grading,excavation,or filling)Byer 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
I
VeralonL7 Commerei! Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 G-F.OF ENCLOSED SPACE)
9.1 Registered Architect:
_.._.. __ ... . ._._.. ._ ._. Not Applicable ❑
Name(Registranip _ ... _
Regisfatpn Number
.ACtlrass
" - . - Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Respo sbility
Address Rcgistraton Number
Signature Telephone Expiation Date
Name Area a(Responsb lty --
Address Registration Number
Signature Ttelephone Expiration Date
Name Area of Responsibility
Address _ __.. .. ...._. _._....__ ._ Re9istabon Number _.
—
Signature Telephone Expiration Date
Name ��---'.. • 'esponsbllty
Address Registration Number
Signature Telephone Expiration Date
9,3 General Contractor
D.rlh,, Dias (d _._, .�_-. .___ .. .___. Nat APpticable 0
Company Name
_pc111 .DC%rL.._
Responsible In Charge of Construction
a ,fDI. °62-
Add •-
-
gyre elePhate
Vermont Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) TI
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11—OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 1 . - �/ 0 -- - as Owner of the subject property
OwNE t-
hereby authorize I"05.1 t61../a ... -_ _.. _.. . to
act on my behalf, in all matters relative to work authorized by this building permit application
Oxy _ (42/5:./ 17
Signature of Ow er Date
i 01+1 1pgcrj -_. , as Owne/Authorize.
to riKACIM-t. — i
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowtedge
and belief.
Signed under the Pains end penatgesof perjury
1'gf1 'Iarl
Pont Nam ----
L
of 0 .ent Dep �._
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Congtruc-tii.n Supervisor. s Not Applicable 0
/Name et❑cense Holler Lt?i'i DqOf1 _.. cr, -105-971 1
License Number
(7 dd y} r14 Dr., o106 /7 /if
A:th: Exp/etc Date
ure / r 611-4g3-ars93
\ s Telephone
S- TION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,425C(6))
J
Workers Co • • - ion Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the Issue = the toilding permit. ___----1-
..--
Signed Affidavit Attached Yes �r !
�_[
The Commonwealth ofMassacleusetts
Departmentnt ofLcdustrial Accidents
? _:;,�` Office of Investigations
lhcr 600 Washington Street
Boston,&L4 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information r1 Please Print Legibly
Name(Business/Organization/Individual): sl! Q>� .V i
Address: a�� ;�)�drej4 !Jf
City/State/Zip: F/o _ l✓!!�CNof3 Phone : • :
Are you an employer?Check the appropriate box- Type of project(required):
1.E I am a employer with 4. am a general contractor and I
employees (full and/or part-time).'
have hired the sub-contractors 6 ❑Ne construction
2,❑ I am a sole proprietor or partner- listed on the attached sheet. emodeling
ship and have no employees These sub-contractors have 8. T Demolition
working for me in any capacity. employees and have workers' 9 Building addition
[No workers' comp.insurance camp.insurance?
required.] 5. C] We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their ILD 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' 13.0 Other
( _ comp. insurance required.]
:Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
'Homowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submits new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the naur of the sub-contractors and state whether or not there entities have
employees. If the sub-con crors have employees,they must provide their workers'camp.policy number.
7 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information, ff Q
Insurance Company Name: t6l5(CL MS CO,— �l
Policy#or Self-ins.Lie #: c 7'JeQ�tn Expiration Date:,)-5'jy-
Job Site Address: / 4mtke /n, 0/00 ,_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 n. 152 can lead to the imposition of criminal penalties of a
tine up to$1,500.00 andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up o$250.00 a day against the violate :e advised that a copy of this statement may be forwarded to the Office of
Investigations of the * ' or ins ... e coy age verification.
I do hereby . til. r und- a pains t -•penalties of perjuy that the information provided above i true and correct.
Signature: _ Date: /1
Phone#: w17 y3 '.
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 150A.
Address of the work:
The debris will .- tran-port=d by:
The debris will . - rec- ve. by: A
Building permit u b -r: -1
Name of Permit Appli :nt
Date Signature of Permit Applicant