12C-112 87 Rick Drive Permit App 2012-05-03File # BP-2012-0931 PA~ elL
AMHERST (413) 687-1817
APPLICANT/CONTACT PERSON DANIEL MUSCAT
ADDRESSIPHONE 133 GRAY ST
PROPERTY LOCATION 87 RICK DR
MAP 12C PARCEL 112 001 ZONE RI(100)/URAOOO)/wSP(100)1
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 12 X 25 SCREEN PORCH & DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Stru~c=tur""e,,-_________________________
Building Plans Included:
Owner/ Statement or License 69679
3 sets ofPlans I 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 PlanAND/OR ____Special Permit With Site Plan
Major Project: Site Plan ANDIOR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §,___~__~___
Finding,___.~__ Special Permit. _______ Variance*____
___Received & Recorded at Registry ofDeeds Proof Enclosed
__Other Permits Required:
___Curb Cut from DPW ___Water Availability ___Sewer Availability
___,Septic Approval Board ofHealth ____Well Water Potability Board ofHealth
/ Permit from Conservation Commission __-,Permit from CB Architecture Committee
__-,Permit from Elm Street Commission ___,Permit DPW Storm Water Management
___.Demolition Delay
Signature ofBuilding 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 ofMGL 40A. Contact Office of
Planning & Development for more information.
City of Northampton
Building Department
212 Main Street
Room 100
rthampton, MA 01060 ~:~~~~5i1e~413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SEctiON 1 -SitE INFORMAtiON
1.1 Property Address:
87 Rick Dr.
SECTION 2-PROPERTY OWNERSHIP/AUTHOR1ZED AGENT··
2.1 Owner of Record:
Rena Johnston
2.2 Authorized Agent:
Dan Muscat I
Signature .
SECTION 3 .~EST1MATED CONSTRUCTI0lrl,cOSTS
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
! 5. Fire Protection
i 6. Total (1 + 2 + 3 + 4 + 5) 000
Building Permit Number: __~_...,-____~.......:."........;;;..
. '. . .
iBuildjrlg CommissibnerflnspectoT QtElUlIdjngs ..
87 Rick Dr., Florence, MA 01062
Current Mailing Address:
584-6776
Telephone
133 Gray St., Amherst~ MA 01002
Current Mailing Address:
413-687-1817
Telephone
(?)Bui1ditigPermit·Fee
(b) Estimated T ctal Cost of
. construction from 6
BuUdingP~rmit.•I=ee
Dale
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 Department
•
Lot Size r LV. 'S '''''' -~l I L j
Frontage ! II J l
Setbacks Front em [-:=] C=:J
Side L:[Z!3 RJ~J T·r-l R.r~1
Rear rmJ (3~
Building Height [~
Bldg. Square Footage ~ L~J% Il'Z~B1 ~ [=:J
Open Space Footage [Nffi] L!!(lJ % ~ ~J &fJerzv(Lot area minus bldg & paved
varking)
# of Parking Spaces [£J
Fill: J(volume & Location)
A. Has a Specfal Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES0 0 0
IF YES, date issued: '----------'
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES0 0 0 r--'-IF YES: enter Book Pagel and/or Document # L-"".".~w.~_~"
B. Does the site contain a brook, body of water or wetlands? NO @ DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained o Obtained 0 , 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 0 NO @
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 0 NO ~
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Replacement Windows Alteration(s)
OrDoors 0oNew House Addition
Accessory Bldg. 0 Demolition New Signs [0] Decks [0
Brief Description of Proposed
Adding new bedroom Yes VNo ~
Renovating unfinished basement ___Yes V No
a. Use of building: One Family __'1..-.;;__ Two Family ____Other ____
b. Number of rooms in each family unit, ______ Number of Bathrooms,______
c. Is there a garage attached? NO
d. Proposed Square footage of new construction., __Z_"1:-S______ Dimensions _--1-J.;..7---AX'--_7__$_-~______
e. Number of stories? __.L..l____________
f. Method of heating? ______________ Fireplaces or Woodstoves _____ Number of each
0 Roofing LJ
Siding [OJ Other [0]
g. Energy Conservation COmpli~p_...,.,..__------Masscheck Energy Compliance form attached? _______
h. Type of construction -,?t:..J.L.~::::..>o<=--1_'-I-'","
i. Is construction within 100 ft. of wetlands? Yes ___ No. Is construction within 100 yr. floodplain ___Yes __No" j. Depth of basement or cellar floor below finished grade -----::--;,r-----'1;
k. Will building conform to the Building and Zoning regulations? ____ Yes ___ No.
I. Septic Tank __ City Sewer ___ Private well ___ City water Supply ___
I, Rena Johnston • as Owner of the subject
property
ap,"lc.:ltIon.
I, J2A.N H()~~r ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Hame of License Holder ::--.!J,~,.IL:.::L-..!!:.....\.ilo.t..~..S::!!::f...l----~~-Y-l',llL--
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the
Affidavit Attached yes...... .
Company Name
Address
_____________________Telephone,_______
The current exemption for "homeowners" was extended to include Owner-occupied Dwellings ofone (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as sup$!rvisor, CMR 780, Sixth Edition Section 108.3.5.1.
Definition ofHomeowner: Person (s) who own a parcel ofland 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, tbat be/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 ofthe work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability ofEmployers to
Employees for injuries not resulting in Death) ofthe 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 ofMassachusetts General Laws Annotated.
Homeowner Signature
The Commonwealth ofMassachusetts
Department ofIndustrial Accidents
Office ofInvestigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/ContractorslElectricianslPlumbers
Applicant Information Please Print Legibly
Name (Bu,mosslO_i""onIIndivUluru): ~~t=
Address: /-;, fi~~ C!:8t (8 (1Phone #:
Are you an employer? Check the appropriate box:
City/State/Zip:
Type of project (required):
1.0 I am a employer with 4. 0 I am a ~eneral contractor and I 6. 0 New construction employees (full and/or part-time). * ~ave hired the sub-contractors 7. 0 Remodeling2.f:7f I am a sole proprietor or partner-hsted on the attached sheet. ~ These sub-contractors have 8. 0 Demolitionship and have no employees
working for me in any capacity. employees and have workers'
9. g Building addition
[No workers' compo insurance compo insurance.+ 16.0 Electrical repairs or additions required.] 5. 0 Weare a corporation and its
11. 0 Plumbing repairs or additions
myself. [No workers' compo right of exemption per MGL
3.0 I am a homeowner doing all work officers have exercised their
12.0 Roofrepairs
insurance required.] t c. 152, §1(4), and we have no
13.0employees. [No workers'
compo insurance required.]
*Any applicant that checks box #1 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,
tContractors 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' compo policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company
.____________________________________ ExpirationPolicy # or Self-ins. Lic .
Job Site Address:,____________________ City/State/Zip:,__________
Attach a copy ofthe workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMGL C. 152 can lead to the imposition ofcriminal penalties ofa
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 ofthe DIA for insurance coverage verification.
Phone #:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: ________________ PermitILicense # _______________
Issuing Authority (circle one):
1. Board ofHealth 2. BuDding Department 3. CityITown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.0ther _____________
Contact Person: Phone#:
--
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City ofNoIihampton, MA: Residential Property Record Card
New Search Property Type Classification Code Reference Card 1 of 1
Parcel -Location - -Assessment
Map-Block-Lot: 12C-l12-001
Location: 87 RICK DR
#Living Units: 1
Class: ' R-lOl
0
Y
I
V I\
13
11
4 B
11
22
>Z5/ r
Zoning:
N eigborhood: 15
Deed Book: 2335
Deed Page: 099
1
"7 '38 1
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35
1FrIO
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Assessment:
Land: 115,200
Building: 87,500
Total: 202,700
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