13-020 (5) 2(r ROCKLAND HEIGHTS RD BP-2005-0178
IT,";;/1 COMMONWEALTH OF MASSACHUSETTS
Map:Block: 13-020 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0178
Project# 3S-2005-0199
Est.Cost: $1000.00
Fee: $15.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN W COTTON 085406
Lot Size(sq. ft.): 42993.72 Owner: DUSEAU MARY B
Zoning: SR Applicant: JOHN W COTTON
AT: 70 ROCV!_ NT) HETGHTS RD
Applicant Address: Phone: Insurance:
P O BOX 921 (413) 247-9608 WC
NORTHAMPTONMA01061-0921 ISSUED ON:8/16/04 0:00:00
TO PERFORM THE FOLLOWING WORK:DEMOLISH DETACHED GARAGE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footing,
Rough: Rough: e Foundation:
t re ' al:
Final: Final:
` D \ Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: :a:::::
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. ._,
Certificate of Occupancy Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 8/16/04 0:00:00 2877 $15.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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File#BP-2005-0178
APPLICANT/CONTACT PERSON JOHN W COTTON
ADDRESS/PHONE P 0 BOX 921 NORTHAMPTON (413)247-9608
PROPERTY LOCATION 20 ROCKLAND HEIGHTS RD
MAP 13 PARCEL 020 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ?oS��l � !;
Fee Paid i/ N
Typeof Construction: DEMOLISH DETACHED GARAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 085406
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 Commis n
tv14" $?/ 4/110 r
Signature of Building 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
I—f Northam pton Status of Permit:
I 1 Department Curb Cut/Driveway Permit
aln Street Sewer/Septic Availability
AUG - 6 200� om 100 Water/Well Availability
Ort am ton, MA 01060 Two Sets of Structural Plans
L _-. bonP 4 - 7-1 40 Fax 413-587-1272 Plot/Site Plans
DEFT OF BUi+ (N MA 01060 Other Specify
NoRi
PLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property A ress: This section to be completed by office
Q Map /3 Lot (e!d Unit
• iUo ,� ,q,{PrZone V Overlay District
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
iJ 4VI D I). A U �`� LC'�
N] e(rnt Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
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 ,� (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number 277
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
•
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume-&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
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:
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House 0 Addition 0 Replacement Alteration(s) 0 Roofing ❑
Windows Or Doors 0
Accessory Bldg. 0 Demolitiond New Signs [ ] Decks [ ] Siding [ ] Other[ ]
Brief Description of Proposed ui(1",,i7
Work: r>be 17n(. .✓4 2 23/+/ 9Of/E70 CI AI•v,4G[
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll U-Sheet
6 ;: -6Viiii ii§6:al .ik:a. I ititiii:t&dkist ig:tiouAi 4.:::✓ ::::::::::: :::dl:aim:ng:
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. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck 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 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 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, l\-->jA t �jSPtx.) , as Owner of the subject
property
hereby authorize /S_ rr - Cs:0 tr to
act on my behalf, in all matters rela ' o work authorized by this building permit application.
Skolature of Owner Date
I, a VVLA✓ may" , 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.
Oj
Print Na e
J
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: 30V-IJ \nJ COfioA/ CS 0 '50Y
License Number
' ec c• 12,E \' y- 2- zoo?
Addressd Expiration Date
AI� 1() � r '�i,3 zy�- 960
gna re Telephone
9.Registered Homelmarovement Contractor: >" Not Applicable 0
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 0 No 0
.....................................................
.................... ...............................
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(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 supervisor.CMR 780, Sixth Edition Section 1083.5.1.
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
.
�Ztt/Jlp2.
a� � �ti� (jii� of Northampton n'iipton ) )—
A � �Za R. 45
s.� rhncclle' _;
���^— DEPARTMENT OP BUILDING INSPECTION'S • —• 3=,
212 Main Street • Municipal Building
Northampton, Mass. 01060 sr`-
WORKER'S COMTENSATION GNSURANCE AFFIDAVIT
I a t / T/✓ ___
(li ccusx/permi ttee) _
will a principal place of business/residence at:
S l )t3t ,5 Z{/ /71 E/2 /Yl/ O/'J (phone') fjJ-2 V7-966b---
(sac t/ci ty/statcfzj p)
do hereby certify, under the pains and penalties of perjury, ilia! .
( I a.rn an employer providing the following worker's cornoensauon coverage for U1\ .
employees worhdng on this job.
7 rJ/L S Z/CO8 ---.973X V09-703 //-zd-c./
(Ijsu.r:.nc Company) (Petit: Nu. r) (r;-pinion Dale) .
( ) I am a sole proprietor, general contractor or homeowner (c'cie one) and have hired
the contractors listed below who have the following worker's coEDpention policies:
(Name of Cont'neio") (Innirance, CompanyfPollci Nurnly:r) (Lxptr ton Dalc)
(Name of Contractor) (Ins,tranc;, Company Policy Nuncrr) (Expiration Dare)
(Name of Conn-aetor) (Insurance CompanycPotic-y Namb(.r) (Expiradou Date)
(Name of Contractor) (Losurancc Company/Policy Numoes) (Expiration Dare)
(ar tch:6±i:ioc31 t5cct if nrocz.ry to¢tcurk'tnforta.Eoo p rtaiaias to.L ooccr-_wort) .
( ) 1 am a sole proprietor and have no one worl3.pg for me
( ) I am.a home owner performing all the work myself.
NOTE:plctc be aware the"t^Je boauAwvera ubo splay peaoas to do r.;ctrz ua t>±�.:e ao c rrpair work on.d"rIl^%of
pot m t th_n throe tmfu in tchith the bomoowvcr rcida a oo the crry tnAt zppuu-tca.rs thc--do LT not Ccic DY eoar:d>czi to be
nployc--s ln'tr-thc«CS-ktez o.,a• .. _tioo Act(GLI 52'a 1(5)),appli�uon by a bomooavn fat:licz�=or V--.tut r�.y c''.76=cce thc
Icp1 tuna of an cr;)loyer uodcr du)Workol.Comp000 iioo Ad
I ll.ockrsta.od the a copy of chi,cntcmcoa m.y bo focw.vd.d to tho Dop.rtmcaa of 1.A.,rrid AoodaotY Office of t,o t'oo.for tho
eovcLac'riGanioe and th.t Lzlt.t to coral=bovcrasc=der soetion 25A of MOL 152 ein lad to the imposition of criminal peaattics
comiriag of a Lux of up to S 1_500.00 and/or inapritioox of up to ooc year and dtil pm.ltic to be form of a Stop Wort Order and.
fur)of 5100.00 a day apiae a c
For dr.o.rur+:--d u.c only
Permit Number
.1 f� CO 11 n' Map::___ Lot „
M
VIA/t
pnatune.o Licrrtsec/Petmiuce Date