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20-006 x BP- 2011 -0338 GIs #: COMMONWEALTH OF MASSACHUSETTS 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- 2011 -0338 Project # JS- 2011- 000554 Est. Cost: $18738.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: GOUGEON & LOCKE 001992 Lot Size(sq. ft.): Owner: ZAWALICK AMELIA K & E HUGHES C/O ELIZABETH HUGHES Zoning: RR/WP/WSPII Applicant: GOUGEON & LOCKE AT. 508 SYLVESTER RD Applicant Address: Phone: Insurance: 26 South Street (413) 268 -9323 Workers Compensation WILLIAMSBURGMA01096 -9726 ISSUED ON. 1011312010 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT SIDING & WINDOWS 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 10/13/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner [parttnent tk qty City of Northampton Statas rPermlt F 3 � 2 Main Street ��+errrtit 1 Buiiding Department Cft/1�Cutip ,J Room 100 1tferettbility Northampton, MA 01060 Tvun Sets ofStfutrttirai Plans phone 413 - 587 -1240 Fax 413 - 587- 1272itlS�te�ne APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address This section to be completed by office Aladler IV Map Lot ' Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record Gfi G�Y /e.S /li� / es 5�� � /rtS ftv' kl I e"i; Name (Print) Current Mailing Address: " � A v Telephone Signature 2.2 Authorized Agent: J'*19F L-W*1�, Z6 SL Name (Print) / Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building �r , p (a) Building Permit Fee 2. Electrical o (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) f 7 ��C? Check Number This Section For Official Use Onl Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date 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 Frontage Setbacks Front Side L: R: L: _ R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg & paved p arking) # of Parking Spaces Fill: ._ (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW YES IF YES, date issued:'. IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 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: 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 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 ❑ Addition ❑ Replacement Wirpdaws Alterations) Roofing Or Doors E Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [bl [0] Brief Descr,j.,pPtion of Proposed Work: L4If/Vi��S7lS Alteration of existing bedroom Yes _L,— No Adding new bedroom Yes L - -- No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet NZIL 6a If New 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 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. 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 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 1, " /`lT� I "UCH as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. 6X2IZC6 &4 Signature of Owner Date as Owne uthorized Agent h eby declare that the statements and information on the foregoing application are true and accurate, to the best of my know a pr' ief. Signed under the pains and penalties of perjury. Print Name Signature of Own Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Su pervisor : Not Applicable 0 Name of License Holder �G'`" r7 �' ' I7 ! 2— License Number Address Expiration Date Signature U Telephone 9. Registered Home Imorovement Contractor: Not Applicable ❑ Company Name d ^ T Registration Number 1 GWN & LOCKF y. Address Expiration Date 1�L1 MA nz__ Telephone SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 26C(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...... ❑ 11. - Home Owner Exemption 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 108.3.5.1. 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