17A-302 (8) J �C<cr5-oma,�. �olahs
115 HILLCREST DR BP-2019-1414
GIs#, COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 17A-302 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Cateeorv:Deck BUILDING PERMIT
Permit a BP-2019-1414
Proiect a JS-2019-002286
Est.Cost:$12500.00
Fee:$81.25 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grow SACKREY CONSTRUCTION 079384
Lot Size(w. ft.): 21867.12 Owner, TURNER DAVID S&MELODIE P
Zonimr URA(100 Applicant. SACKREY CONSTRUCTION
AT. 115 HILLCREST DR
Applicant Address: Phone. Insurance:
83 SOUTH MAIN ST (413)665-9995 O
SUNDERLANDMA01375 ISSUED ON.611712019 0:00:00
TO PERFORM THE FOLLOWING WORK REPLACE EXISTING WOODEN DECK WITHIN
SAME FOOTPRINT
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 Occuoancv signature:
FeeTvpe: Date Paid: Amount:
Building 6/1720190:00:00 $81.25
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File k BP-2019-1414
APPLICANT/CONTACT PERSON SACKREY CONSTRUCTION
ADDRESS/PHONE 83 SOUTH MAIN ST SUNDERLAND (413)665-9995 Q
PROPERTY LOCATION 115 HILLCREST DR
MAP 17A PARCEL 302 001 ZONE URA000Y
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OU ��
Fee Paid 11 .2
Building Permit Filled o
Fee Paid
Typeof Construction: REPLACE EXISTING WOODEN DECK WITHIN SAME FOOTPRINT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 079384
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOIEMATION 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
Si ature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all inning
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 ,
City of Northampton Status of Permit:
4 i Building Department Curb CuuodvewayPermit
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,ALTER,REPAIR,RENOVATE O VEWDAMI DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: hi&yh*JohtIbkW66mpI ted office
NS + iLLc- s-r W . ISA- 3oz—
Map Unit
OE Wn1HaMPI ON.MH�
VO , t 1AAA D 10 b'L zone strict
Elm SL District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZEDAGEitT
2.1 Owner of Record:
Mft,,u,Dil -tuK+[n.Pr--
Name(Prim) Current Meiling Addreas:
yl a - S 2T— 7yS 3
Tebphone
Signature
2.2 Authorized Agent: ('
,10* -k III , S AL� b-6 S . luAir Q �C, JlA cA"+RIAuD
Name(Pdnt) Current Melling Address:
V17 - 5'63 . 1. 639
Slgre Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed brmltapplicant
1. Building )� S db b (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) I '
5.Fire Protection 1 1
6. Total=(1 +2+3+4+5) 12 V" Check Number (-12,
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: 6- 13-261
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
5T ��zu4wf �X � ST�r1l> �Z fl���T
' Section 4. ZONING All Information MusFWtompleted. permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
1 N N Buie Building
Zgmm�entto be ad in by
1111 Building pepmnenr
Lot Sim
Frontage _-
Setbacks .Front O
Side L: R L: R:
Rear
Building eight
Bldg.Square Footage % .I
Open Space Footage ,
(W use minus bldg&paved .J
#ofParking Spaces
Fill:
(volume&Lowrion
A. Has a�Spe/cial Permit/Variance/Finding ever been issued for/on the site?
L`7
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 G 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
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavalb.on,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 0 Addition 0 Replacement Windows Axeration(s) 0 Roofing O
Or Doors 0
Accessory Bldg. ❑ Demolition 0 New Signs [o) Decks [INK Siding[pj Other[r_0
Brief Description of Proposed
Work, A¢PEAOTlu.IL/fr wdbID" DBclIc !Wifiks 5A-Kkk �TPkILI�•
Alteration of existing bedroom_Yes�No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ss.H Now 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 mere a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
I. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 fl.of wetlands?_Yes _No. is construction within 100 yr. floodplain_Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank_ City Sewer Private well City water Supply
SECTION To-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ,as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this Wilding permit application.
Signature of Owner 11 f Date
I, " C) K*A
,as Owner/Authorized
Agent hereby declare that the statements and information n the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalb of perjury.
O J( �
Print Name
Signature of Owner/Age Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:,, Not Applicable ❑
Name of Ucense Holder: 1�0 VkV4 df—S-0-7 9 3 S V
c Ucenx Number
wr,,.l �7i)nlDlFvec aa� �D 10% Y/zo
Address Esq Date
n J �. 43 - s (e3 - 66. 31
Signature Telsoano
8.Registered Home Improvement Contractor: Not Applicable D
SA,cAs-s.�-, CAA-6e . Co - I (0`74 b9
Company Name r Registration Number
S 2) S . Va h.�Q Sur+UlewLc ea/ CD o zo
Address Expiration ate
Telephpne 'l l 3. 563'4 4'r'�
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.182,§25C(8))
Workers Compensation Insurance affidavit must be completed and submitted with this appiicabon. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... W' No...... ❑
City of Northampton
Q'7—
Massachusetts DBPAR2'IIINT OF BUILDING INSPECTIONS212 Hain Stink 01n iclpal Buil,UngNoxtAton, HA 01060 emp
Debris 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.
The debris from construction work being performed at:
(Please print house number and street name)
Is to Ibe disposed of at:
/4111 f2 n �rzL! t U ,dry (r— V�dY�744}}k P
(Pleaselprint name a d location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
El�
Signature o I
Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
x 9 LIN The Commonwealth ofMassaehusetts
Department ss Street,Indust
Suit ccidents
1 Congress Sdeey Suite 100
Boston,MA 02114-1017
wwnsmassgov/dia
U,krkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WHO THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeihlv
Name (Business/Organization/Individual): S car col t S'T
Address:—5 3 5 , " A-y.Q
City/State/Zip: PIW Phone#: kf1 1, 5-6 3 G G 3 t
An you an employer?chars the appropriate laps: Type of project(required):
1.�am a employer with q employces(fell emberpmt-time).' 7. ❑Newconstmction
2. 1mnaaxleproprietorwI> mhipmrdhavememployeesworking f«mein
8. r]Remodeling
any capacity.[No workers'camp.insurance required.]
3.❑I em a homeowner doing all work mymlf.[No wodmrs'camp.insurance requimd.l r 9. El Demolition
4.❑l mn a Immmwnm and will be hiring eontmemrs m mndmt all work m my property. I will 10❑Building addition
amore that all contactors either have woreers'emaga etion insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employes.
12.[]Plumbing repairs or additions
501ama genemlcontm;have a plohaveeiredthave w. .'eirspin ont6eattached sheet. 13.E]Rpof airs
These subcontractors have employes and have workers'comp.insurarme.r �
6.❑We area corporation m,d its officers have exercised theirright ofexerwhon per MGL c. 14.❑Other
152,g1(4),and we have m employees.[No workers'comp,inamenn required.]
'Any applicant that checks box 41 most also fill out the section below showing their workers'compesimmon polity inforreatim.
I Homcowmers who submit this affidavit indicating they are doing all work and the hire outside contractors must submit a new affidavit indicating such.
lCummetors that check this box must attached an additional sheet showing the rmmc of the sub-contractors and state whether or not those entities have
employees. If the subeomracum have employees,they most provide their workers'romp.policy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
injormation �t ,I
Insurance Company Name: 1 A
W
Policy#or Self-ins.Lic.#: lrlilgtSflrt 't 1. Expiration Date: 2 Zp
Job Site Address: I �� �L(-•C"V, ACOAX*XCK City/State/Zip:
Attach a copy of the workers'compensation pailicy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fore 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby ceT=
n thepoins and ena/ties ofperjury that the information provided above is hue and correct
Simature: Date 64/o
Phori
Official use only. Do not write in this area,to be completed by city or town o,OFciot
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CBy/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: