29-214 • J
-
SECTION 8 - -- CONSTRUCTION SERVICES
8.1 Licensed Construction � Su � p � ervisor: Not Applicable ❑
—
Name of License Holder : .1E','55 I eej 077 L 1 0
License Number
L i D Qat S4 t /a , / //
Address Expirati Dat
X13 - Y - 046 ) -t
Telephone
9:` Rectlstne1mtXiotr )ent;ltir>khrarF I . T a., �. .V _ ..,A. #._ pp ❑
M s. � Not Applicable
e 55 e / J°k.'e� 1 r 9
J 37
Company Name Registration Numb
\--I a Oc, cSf /0 /
Address Expirati at
I (ertV) Ze AM. 0 (06 Telephone ,1 s D4
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 ❑ No ❑
s Q)I)E1 1)r' by
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
. t
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ ReplacementiWjpd ows Alteration(s) [J Roofing El
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [D Siding [0] Other [0]
Brief Description o Proposed
Work: ec . t � rieN4 rett ors 4-® , e °G °"a �5 4
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ‘../"----
No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
Vet #"ttiWiS i 'ilafo difi oiiiWgirstinq' ii+ii iTiiiiaiiniif ttie faiaiiiti a:
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, 4 :1. l�o�-e tti C 61 fr'I -e , as Owner of the subject
prop rty /�
hereby authorize :e Ss e C `eyt e
to a
& 7f/7 y behalf, in all ma relative to work authafzed by this building permit application.
er��
Si natu of D e
I, �Ri ?t ee DCY11 S5c O►4r� ► , as Owner /Authorized
Agent hereby declare that the sta e nts and informatio on egoing application are true and accurate, to the best of my knowledge
and belief.
Sir - • under the pain and penalties • f perjury.
�'' _ , • --- se55e /''1�
G et4Al0en 1- 1 . - 7 r
Sig natei.f Owner/Agent j � Date
r
♦ u
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete In rmation ,
Existing Proposed Required by Zo ing
This column to be, filled in by s
Building Departrlient :
Lot Size _ ' ~
, ` 1
Frontage : i i s "'^ "- r
Setbacks Front Lmm ___ i ` °" ` �
Side L: 1 RA _____I L:1 1 R:! 1 b f I
Rear
,
Building Height = i
Bldg. Square Footage = i 1% E 1 4
Open Space Footage %
(Lot area minus bldg &paved a 1 1 _I i 1
i ? .....1
parking)
# of Parking Spaces
Fill: J 11
(volume & Location)
�F ii
A. Has a Special Permit /Variance /Finding r been issued for /on the site?
NO Q DONT KNOW YES 0
IF YES, date issued:!
i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I f 1 and /or Document #:
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW
er
YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:
Mwvw_., .
C. Do any signs exist on the property? YES 0 NO er
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 er
IF YES, describe size, type and location: 1 i
E. Will the construction activity disturb (clearing, grading, exca 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.
. ,
�G C ity of Northampton 4 �.
�SG Building Department , b Ali ��.� 1. 1,ki
Z. 212 Main Street d $ 4 C
' Z Room 100 , ta• 4 .. 1 , "° -�,
iikk ` Q orthampton, M A 01060 , _ P 4 '`�i 1. `"
ems • Is"? one 413 - 587 -1240 Fax 413- 587 -1272 - , a -
8 se a ,�.. 'ti x 3 �� m'. ' '
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1'- SITE INFORMATION
This section to be completed by office
1.1 Property Address:
' i 1 of . V— D Map Lot Unit
c10 re e /t'lA 01 06 a Zone Overlay District
Eim St. District CB District
SECTION 2;- PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
tZ �''hP / 40-to , b k P.-
Name
am fib) Cur MaiHng Addres • _ s 311
�� 61 Q4/ Telephone e(t 6
p
Signatunk)
2.2 Authorized Agent:
7. e55c /t1, c . K Si-. GCorryc -t ,/
Name (Print) - -- Jo' Current Mailing Address:
_ -=.∎ -- f� X13 -,S15" ,
Signa�� /�' Telephone
SECTION 3' ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
_ com leted by permit applicant
1. Building (a) Building Permit Fee
_ / U
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) 0 /C XS?) Check Number 3
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
117 ACREBROOK DR BP-2011-0883
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 214 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit# BP- 2011 -0883
Project # JS-2011-001441
Est. Cost: $10850.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JESSE MONTGOMERY 077410
Lot Size(sq. ft.): 17031.96 Owner: BUSH MICHAEL R & ELIZABETH J DENNE
Zoning: URA(100) / /WSP Applicant: JESSE MONTGOMERY
AT: 117 ACREBROOK DR
Applicant Address: Phone: Insurance:
P 0 BOX 329 (413) 585 -8482
LEEDSMA01053 ISSUED ON:5/2/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS & DOOR
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 5/2/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
117 ACREBROOK DR BP- 2011 -0883
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 214 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit # BP- 2011 -0883
Project # JS- 2011- 001441
Est. Cost: $10850.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JESSE MONTGOMERY 077410
L3t. c .c, c `t. 17031.96 Owner_ _EU51-1 .MICHAEL R & ELIZABETH J DENNE
Zoning: URA(100) //WSP Applicant: JESSE MONTGOMERY
AT: 117 ACREBROOK DR
Applicant Address: Phone: Insurance:
P O BOX 329 (413) 585 -8482
LEEDSMA01053 ISSUED ON :5/2/2011 0 :00 :00
TO PERFORM THE FOLLOWING WORK: INSTALL REPLACEMENT WINDOWS & DOOR
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Numbing 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:
e11: Irr- .il'atie:r :
Final: Smoke: Final: 3 j - -S7 —f(C
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND RE • 1 ' § ► S
d eli/ , old-ckz• >
p
Certificate of Occupan Signature:
FeeType: Date Paid: Amount:
Building 5/2/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck – Building Commissioner